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NERVOUS AND MENTAL 
DISEASES 



BY 

ARCHIBALD CHURCH, M.D. 

Professor of Nervous and Mental Diseases in the Northwestern University Medical School, 

Chicago ; Late Professor of Neurology in the Chicago Polyclinic j Neurologist 

to St. Luke's, Wesley, and Mercy Hospitals ; Consulting 

Neurologist for the Michael Reese 

Hospital, etc. 



AND 



FREDERICK PETERSON, MD. 

Ex-President of the New York State Commission in Lunacy ; Formerly Professor of Psychiatry, 

Columbia University; Consulting Alienist, Bellevue Hospital; Manager of the 

Craig Colony for Epileptics at Sonyea, New York ; Ex-President 

of the New York Neurological Society. 



WITH 350 ILLUSTRATIONS 



EIGHTH EDITION, THOROUGHLY REVISED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 






COPYRIGHT, 1899, BY W. B. SAUNDERS. REPRINTED OCTOBER, I899. REVISED, REPRINTRD, AND 

RECOPYRIGHTED JULY, I9OI. REPRINTED APRIL, 1902. REVISED, REPRINTED, AND RECOPY- 

RIGHTED AUGUST, I903. REPRINTED MAY, 1904. REVISED, REPRINTED, AND 

RECOPYRIGHTED AUGUST, 1905. REPRINTED JUNB, 1906, / ND OCTOBER, 

1907. REVISED, REPRINTED, AND RECOPYRIGHTED AUGUST, 1908. 

REPRINTED MAY, 1910, AND OCTOBER, I9IO. REVISED, 

REPRINTED, AND RECOPYRIGHTED OCTOBER, I91I. 

REVISED, REPRINTED, AND RECOPYRIGHTED 

SEPTEMBER, 1914. 



Copyright, 1914, by W. B. Saunders Company. 






,<. 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



OCT -6 1914 

CU879885 
ft 



PREFACE TO THE EIGHTH EDITION. 



The opportunity for an eighth edition has permitted a careful reading 
of the text for the section devoted to Nervous Diseases. Only a few 
material changes have been made. The subject of vertigo and its 
labyrinthine relations, as developed by Barany, has received careful 
consideration under the discussion of the diseases of the vestibular 
portion of the eighth nerve. In the section on Infantile Paralysis 
much new matter has been added. The whole subject of Syphilis of 
the Nervous System had to be carefully scrutinized in order to bring 
the matter up to the recent epoch-making discoveries in this branch. 
Throughout the work references to the new investigations of the 
spinal fluid, and the relation of spinal fluid changes to the various 
organic diseases of the brain and spinal cord have been introduced. 
The knowledge of the relation of glands of internal secretion to nerv- 
ous disorders has also advanced materially since the appearance of the 
seventh edition, and such facts as have become of established impor- 
tance have been added to the text. Tetany has been definitely placed 
in the group of nervous diseases associated with glandular disorder. 
Altogether, one hundred and fourteen sizable interpolations have been 
made, and over two hundred minor alterations. The continued popu- 
larity of the book among teachers and practitioners is a matter of 
great gratification to the authors. 

September, 1914. 



PREFACE 



This book has been written for medical students and general prac- 
titioners. It makes no claim to be other than a carefully prepared 
text-book. The literature of neurology and psychiatry has been sifted 
by the authors, and such digest revised in the light of their own 
experience in practice and in teaching. They have attempted to 
present their facts clearly, directly, and with brevity, despite the diffi- 
culty of condensing two great subjects within the limits of a single 
volume. 

This is not the joint work of two writers, but each author — Dr. 
Church in Neurology, and Dr. Peterson in Psychiatry — has con- 
tributed to the making of a single volume what might have made 
a separate monograph ; each is, therefore, solely responsible for the work 
in his own department. In placing the correlated sciences neurology 
and psychiatry under the same cover, the reader's convenience was 
considered. 

An unusual number of illustrations for each department (from the 
authors' own material, except when otherwise indicated) has been 
allowed by a generous publisher. 



CONTENTS. 



NERVOUS DISEASES. 



PART I. 

PAGE 

Examination of Patients . 17 

Chapter I. The Anamnesis 17 

Chapter II. The General Physical Examination . , 24 

Chapter III. The Muscular System 28 

Errors of Motility 28 

The Reflexes 32 

Chapter IV. Trophic Conditions 39 

Chapter V. Electrical Conditions . <- 41 

Chapter VI. Sensory Conditions 49 

The Tactile Sense 50 

The Pain Sense 51 

The Pressure Sense 51 

The Thermic Sense 51 

The Muscular Sense 54 

Pain 57 

Chapter VII. The Special Senses 62 

Sight 62 

Hearing 65 

Smell 66 

Taste 66 

Chapter VIII. Speech 67 

PART n. 

Diseases of the Cerebral Meninges and Cranial Nerves 72 

Chapter I. Cerebral Meninges 72 

Pachymeningitis 74 

Pial Hemorrhage 76 

Chapter II. Inflammation of the Pia Mater 78 

Acute Leptomeningitis 78 

Varieties of Leptomeningitis . . . . . . o . 90 

Diplococcus Meningitis , . . . 90 

Tubercular Meningitis ......;. „ 91 

Serous Meningitis 97 

Chronic Leptomeningitis 98 

Chapter III. Diseases of the First and Second Cranial Nerves . ........ 99 

Chapter IV. Diseases of the Ocular Nerves . 108 

Chapter V. Diseases of the Trifacial Nerve . 117 

Chapter VI. Diseases of the Facial Nerve 123 

Chapter VII. Diseases of the Eighth Cranial Nerve 132 

Chapter VIII. Diseases of the Glossopharyngeal, Vagus, and Accessory Nerves . 140 

Chapter IX. Diseases of the Spinal Portion of the Accessory Nerve ...... 151 

Chapter X. Disease of the Hypoglossal Nerve 154 

Chapter XI Multiple Paralyses of Cranial Nerves 156 

11 



12 CONTENTS. 

PART m. 

PAGE 

Diseases of the Brain Proper 167 

Chapter I. The Cerebral Cortex — Localization 167 

Chapter II. Speech and the Cortex — Aphasia 176 

Chapter III. The Cerebral White Matter, Basal Ganglia, and Cerebellum ... 186 

Chapter IV. Further Localizing Considerations 194 

Chapter V. Arterial Brain Diseases 199 

Cerebral Anemia and Hyperemia 201 

Cerebral Arteritis 204 

Chapter VI. Cerebral Hemorrhage and the Hemiplegic State 209 

Chapter VII. Cerebral Softening 224 

Chapter VIII. Diseases of the Cerebral Veins and Sinuses 233 

Chapter IX. Cerebritis, Encephalitis, and Abscess of the Brain 240 

Chapter X. The Cerebral Palsies of Children 248 

Chapter XI. Tumors of the Brain 258 

Chapter XII. Hydrocephalus 273 



PART IV. 

Diseases of the Spinal Meninges and Spinal Nerves 278 

Chapter I. Spinal Meningitis and Spinal Meningeal Hemorrhage 278 

Chapter II. Injuries and Diseases of Spinal Nerves 286 

Chapter III. Lesions of Special Spinal Nerves 297 

The Cervical and Brachial Plexuses 297 

Combined Palsies of the Nerves of the Arm 304 

Nerves of the Trunk 308 

Nerves of the Lower Extremity 308 

Chapter IV. Multiple Neuritis , 317 

Chapter V. Herpes Zoster 337 

PART V. 

Diseases of the Cord Proper 340 

Chapter I. Localization . . 340 

Chapter II. Indiscriminate Cord Lesions 362 

Traumatic Lesions of the Cord Substance 362 

Hemorrhage into the Cord 362 

Thrombotic Softening of the Cord 364 

Myelitis 365 

The Paraplegic State 373 

Landry's Paralysis 3/6 

Caisson Disease, or Divers' Palsy 380 

Tumors of the Spinal Cord and Its Envelopes 382 

Spina Bifida 386 

Chapter III. Lesions and Diseases of the Spinal Gray Matter 388 

Acute Anterior Poliomyelitis 388 

Syringomyelia 398 

Progressive Muscular Atrophies Showing Lesions of the Spinal 

Gray Matter 406 

Progressive Muscular Atrophies without Striking Cord-lesions . 414 

Arthritic Muscular Atrophy 425 



CONTENTS. 13 

PAGE 

Chapter IT. Lesions Affecting the White Matter of the Cord 427 

Tabes Dorsalis 428 

Combined Scleroses of the Spinal Cord 463 

Combined Cord-lesions in Anemias and Cachexias 466 

Family Ataxia , . . . 468 

Hereditary Spastic Paraplegia 475 

Sclerosis of the Cord Due to Vegetable Intoxicants 476 

PART VI. 

Diseases of the General Nervous System with known Anatomical 

Basis «... 479 

Chapter I. Multiple Cerebrospinal Sclerosis „ . . 479 

Chapter II. Syphilis of the Nervous System 487 

Cerebral Syphilis „ „ 489 

Spinal Syphilis „ „ 495 

The So-called Parasyphilitic Diseases. .-.-.....<,... 499 

PART vn. 

Diseases of the Nervous System without Known Nervous Anatomical 

Basis 501 

Chapter I. Trophoneuroses 502 

Acromegalia 503 

Adiposity and Genital Dystrophy 510 

Trophoneuroses Related to the Thyroid and Parathyroid Glands. 513 

Myxedema 514 

Exophthalmic Goiter 523 

Scleroderma 534 

Tetany 536 

Eaynaud's Disease 540 

Acroparesthesia 543 

Intermittent Limping 543 

Angioneurotic Edema 545 

Hyperostosis Cranii 548 

Hypertrophic Osteoarthropathy 549 

Localized Hypertrophies 550 

Chronic Hereditary Tropho-edema 552 

Chapter II. Infection Neuroses 553 

Tetanus 553 

Hydrophobia 556 

Chorea . 558 

Chapter III. Motor Neuroses 8 e 570 

Huntington's Disease D 4 570 

Myoclonia ... 571 

Dubini's Disease . . 573 

Parkinson's Disease, Paralysis Agitans , 574 

Thomsen's Disease (Myotonia) . 580 

Family Periodic Paralysis 583 

Family Tremor . 584 

Chapter IV. Fatigue Neuroses 585 

Writers' Cramp 585 

Other Occupation Neuroses , 591 

Chapter V. Neurasthenia 592 

Chapter VI. Psychasthenia 602 

Chapter VII. Motor Tics 606 



14 CONTENTS. 

PAGE 

Chapter VIII. Hysteria . 610 

Stigmata of Hysteria „ 613 

Accidents of Hysteria 621 

Chapter IX. Epilepsy . 639 

Chapter X. Migraine ...„...-. 653 

Chapter XI. Neuroses following Traumatism ."*'..'. 658 

PART VIII. 

Symptomatic Disorders . . 660 

Chapter I. Neuralgia „ 660 

Chapter II. Disorders of Sleep 666 

Wakeful Disorders of Sleep 668 

Somnolent Disorders of Sleep 672 

Sleep Palsies 673 

Hypnotism 674 



MENTAL DISEASES. 

Chapter I. Definition and Classification of Insanity 679 

Chapter II. General Etiology of Insanity 689 

Sex; Age; Heredity 689 

Strain 713 

Chapter III. General Symptomatology of Insanity 728 

Disorders of Sensation 729 

Disorders of Ideas 735 

Affective Disorders 737 

Disorders of the Idea-associations .... 740 

Disorders of Actions 749 

Accompanying Physical Disorders 751 

Chapter IV. Methods of Examination 756 

Family History and History of the Patient 758 

Observation of the Patient . „. 759 

Examination of the Patient's Physical and Mental Condition . . 761 

Chapter V. General Treatment of Insanity 767 

Treatment of Acute Cases 772 

Chapter VI. Manic-Depressive Insanity 781 

The Manic Phase 784 

The Depressive Phase 789 

The Circular or Alternating Type . 794 

Involution Melancholia . 799 

Chapter VII. Dementia Praecox 802 

The Hebephrenic Form 807 

The Catatonic Form 808 

The Paranoid Form 809 

Chapter VIII. Senile Dementia and Other Senile Psychoses 810 

Senile Dementia 811 

Other Senile Psychoses 813 

Chapter IX. Paralytic Dementia 813 

Chapter X. Paranoia 827 

Chapter XI. The Neuropsychoses 80I 

Hysterical Insanity; Epileptic Insanity ,. 80 1 

Chapter XII. Idiocy • • • • 859 

INDEX • • 911 



NERVOUS DISEASES 

BY 

ARCHIBALD CHURCH, M.D 



NERVOUS DISEASES. 



PART I. 

EXAMINATION OF PATIENTS. 



CHAPTER I. 
THE ANAMNESIS. 



Diagnostic investigation in neurological work is a matter of pains- 
takiug care and thoroughness. A correct opinion depends upon it. It is 
the first step toward treatment, the legitimate end of medicine. The 
physician is dealing with morbid conditions, revealing themselves for the 
most part by functional errors. The large subjective side of the problem, 
with the unreliability of the patient's response, adds to the difficulty and 
calls for keenness of judgment at every step. The use of several tests for 
determining a given state is of much importance, especially in conditions 
that are not objectively evident. By comparison of the results thus 
obtained, and sometimes by striking an average of such results, exactness 
may be approximately reached, while dependence upon any one of them 
might be misleading. 

On the other hand, by the use of instruments of precision, controlled 
by anatomical and physiological rules, a definiteness can often be reached 
in nervous diseases not elsewhere possible. Localization in brain 
and cord lesions is sometimes exact to a degree, and prognosis is often 
absolutely clear. But in many instances of the so-called functional 
diseases, careful study, the shrewdest judgment, and a wide experience 
enable one only approximately to appreciate the situation. The entire 
data can be secured only by a systematic and frequently prolonged or 
often-repeated examination, and it is of the first importance that the 
medical man should maintain an entirely judicial and non-committal 
mental attitude toward his patient and the diagnosis until he has every 
available fact at his disposal. Snap-shot diagnoses may be gratifying 
to all concerned, if correct, but they are very likely to be wrong and 
prejudicial to a proper subsequent estimation of the case and are never 
necessary. 

A systematic examination can not be made without a prearranged 
formula. The nearer this corresponds to the development of the 
case, the less likely are important matters to be overlooked. It 
therefore should be chronological. Most patients insist on telling their 
own stories in their own way. It is sometimes well, especially in 
private practice, to allow them to do so, and when they finish, to begin 
2 17 



18 NERVOUS AND MENTAL DISEASES. 

properly. In nervous diseases the family history is often of paramount 
importance. Taken with the appearance of the patient, it gives valu- 
able indications as to the constitutional make-up of the individual. 
The family history, then, is to be investigated first, after noting 
the name, age, sex, nationality, occupation, and social state of the 
patient. 

Neurotic Heredity. — In seeking information regarding the ante- 
cedents of a patient, much tact must sometimes be employed. Patients 
are loath to detail matters of this character, not always from a wish to 
conceal them, but from disinclination to admit even to themselves any 
serious shortcoming or morbidity. To the half that is directly learned 
an equal amount may sometimes be reasonably added. Much can be 
learned by interrogating other members of the family, especially if 
related by marriage, the family physician, and old acquaintances, but 
the confidence and rights of the patient must not be forgotten. Nor is 
it sufficient to seek for instances of the identical disease in the family 
history of the case. The significant factor is a neuropathic liability, 
and this is indicated with more or less force by the appearance of ner- 
vous and mental diseases of any sort, of slight or serious degree, in the 
ascendants. For instance, a hysterical mother has an epileptic child 
and an idiotic grandchild ; or highly wrought nervous organizations in 
mother and father eventuate in neurasthenic and unstable children. 
Atavism in mental and nervous diseases is quite common. Insanity in 
the same or neighboring generations may alternate with neuroses or 
mild psychoses, and any combination may exist. Consanguinity on the 
part of parents, in addition to furnishing a tendency to infecundity, is 
likely to bring together the subjects of similar neurotic taints, which 
are thereby reinforced in the offspring. In itself, however, consanguinity 
has probably been overestimated as a causal factor in nervous and 
mental diseases. The association of crime, precocity, genius, neuroses, 
and psychoses in related individuals may be encountered. Certain 
nervous diseases are of direct hereditary character, being transmitted 
from generation to generation or appearing in a group of cases in a 
given generation. It is only needful to mention Friedreich's ataxia 
and Huntington's chorea, but tabes dorsalis, paralysis agitans, multiple 
sclerosis, muscular atrophies, and practically every organic and functional 
nervous disease occasionally presents family groups of this nature. 1 
Many of the familial diseases which have been described as essentially 
distinct are found to insensibly merge through the observation of inter- 
mediate cases; and Baumlin 2 contends that all typical diseases of a 
familial character drift into each other through such connecting links. 
A family constitutional defect is the only essential feature. 

Debilitating diseases, like tuberculosis, rheumatism, and gout, are 
significant. Indeed, Charcot was inclined to consider arthritism as a 
congener of nervous diseases. Inherited syphilis is on an entirely 
different footing. Not only is it capable of producing embryological 

1 Ch. Fer6, " La Famille Nevropathique, " Paris, 1894. 

2 "Deut. Zeit. f. Nervenheilk.," Oct., 1901. 



THE ANAMNESIS. 19 

defects, but its blight may make itself evident on the part of the 
nervous apparatus during the period of growth or in adult life, modify- 
ing cerebral or spinal functions and at times leading to histological 
changes in the central and peripheral parts, which may vary in degree 
up to destructive lesions. Diabetes and Bright' s disease are very com- 
mon in neurotic families. 

Personal History. — The investigator should go most carefully into 
the medical life-history of his patient. While doing so, indeed, when- 
ever opportunity offers, the conduct, attitude, manner, gait, posture, 
complexion, expression, gestures, and individuality of the person should be 
keenly watched. This observation becomes in time a trained, almost 
automatic, faculty, so that minute details subconsciously apprehended at 
the time can be readily recalled. 

In infancy, was there any birth difficulty, possible brain or spinal 
injury from protracted labor, precipitate labor, or instrumentation ; lack 
of vigor, suspicion of syphilis, or convulsions ? During childhood, did 
the patient present any nervous phenomena, such as marked delirium or 
spasms under febrile conditions or from irritation of the gums and in- 
testinal tract? Was there enuresis, chorea, somnambulism, or night- 
terrors ? Was he precocious or otherwise, docile or obstinate, cheerful 
or morose, forward or retiring ? At pubescence, were there mental 
changes of unusual character, moodiness, expansiveness, cruelty ? Was 
the establishment of menstruation attended by pain or hysterical mani- 
festations ? Was masturbation indulged in or suspected ? During adoles- 
cence, what was the career, relation to the opposite sex, success in school 
and business, and what has been the course of events through adult life f 

The past illnesses of the patient should then receive attention in 
the same systematic manner. The fevers and febricula of childhood, 
the exanthemata and infections. The diseases of the nasopharynx, 
stomach, intestines, and rectum, of the lungs and heart, of the skin, the 
special disorders of chest, abdomen, pelvis, and genito-urinary apparatus 
must not escape attention. Especial inquiry should be made for rheu- 
matism, gout, grip, and malaria. The venereal history of the patient and 
the possibility of specific infection should in every case be carefully 
inquired into. This is a rule that has no exceptions. The investiga- 
tion must be modified and guarded according to individual circum- 
stances, but nothing should deter the physician from making sure that 
a factor of this sort is not overlooked. If injuries have been received, 
w T hat were their character and consequences ? Regarding habits, it is 
to be borne in mind that neurotic people are especially liable to carry 
everything to extremes and are prone to become the abject subjects 
of some perverted practice or stimulant addiction. Masturbation and 
venery take firm hold on them. Tobacco, alcohol, morphin, cocain, 
chloral, and even tea and coffee master them completely. These in 
turn often break down the moral status of the individual and make 
him unreliable and untruthful. Only inadvertently or at second 
hand does the physician sometimes gain the required information, but 
justifiable suspicion once aroused, he can usually go to the root of the 
matter. 



20 NERVOUS AND MENTAL DISEASES. 

In neurasthenic, hypochondriac, and hysterical cases frequently the 
patient has most seriously overestimated some such habit, is morbidly 
apprehensive as to its results, exaggerates its every relation, and the 
entire life seems to revolve around this central erroneous idea. One 
must avoid being led by such unfortunates into adopting their point of 
view. The details, duration, and probable effect of the habit being 
clearly understood, its morbific influence can be properly estimated. 
Let it never be forgotten that many of these habits are symptoms, not 
causes, of nervous disturbance, and are the result of an underlying 
predisposition upon which they are grafted. There they take on a 
morbid development and, in turn, no doubt, add to the unbalance of the 
individual. 

The residence or habitat of the patient is an important consid- 
eration. It calls attention to the climatic and local conditions favoring 
health or disease. Unhealthful surroundings are of immediate concern, 
and throw a strong light upon the causation of many nervous disorders. 

Occupation. — Many occupations predispose to nervous maladies 
and sometimes furnish the cause. Indeed, a group of diseases is known 
as occupation neuroses, of which writers' cramp is a type. Workers in 
metals, particularly those handling lead, phosphorus, mercury, and 
arsenic ; people subjected to illuminating gases or bisulphid of carbon, 
and those who deal in alcoholics, and who are thereby likely to over- 
indulge, are subject to neuritides and associated mental disturbances. 
Work requiring exposure to cold and conditions favoring rheumatic 
processes entail a tendency to cerebral arterial mischief and peripheral 
palsies. Divers and those working in caissons, or elsewhere, under 
increased atmospheric pressure frequently present spinal lesions with 
paraplegic symptoms. Occupations which demand constant mental 
strain and sedentary habits, as in speculative mercantile life, teaching, 
and some of the professions, furnish large numbers of neurasthenics. 
On the other hand, the unoccupied are likely to become selfish, intros- 
pective, hysterical, and hypochondriac. 

The Illness. — From the patient's statement, his personal history, 
and the physician's observation, the noting of the details of the illness 
under consideration is often a simple matter. The medical man from 
his special knowledge must supplement the impressions of the layman. 
In the ■" rheumatism " preceding ataxia he discerns initial features of 
tabes, and in some long-antecedent moral shock he recognizes the origin 
of the fixed hysterical idea that may have eventuated in a contracture. 
For each major group of nervous maladies, psychic, cerebral, spinal, 
and peripheral, he must follow out the clues his training recognizes or 
his studies and experience suggest. 

Beginning with initial symptoms and alleged, suspected, or positively 
known causal conditions, the manifestations of the disease are to be 
systematically, briefly, and clearly developed and noted, with full atten- 
tion to remissions, intermissions, or relapses. In convulsive disorders a 
full clinical investigation of the attack is of prime importance. It 
should embrace its exciting cause, onset, features of consciousness, 
motor signs and phenomena, attitudes, duration, termination, and 



THE ANAMNESIS. 21 

sequelae. In sensory disturbances investigate the particular dysesthesia 
or pain, its onset, exact location and outlines, its intensity, duration, 
and associated conditions. In paralytic maladies determine the mode of 
onset, exact distribution, and the character and degree of motor failure. 
The mental symptoms are to be noted with equal care, attention being 
directed to their fixity, emotional character, and reasonableness or com- 
plete opposition to facts within the patient's range of knowledge. An im- 
portant question is whether the patient can correct his morbid ideas by 
mental effort or is entirely subjugated by his delusional states. Finally, 
the tendency to improvement or the reverse should be indicated. 

Physiognomy of the Patient. — Formerly it was considered suf- 
ficient to describe a patient as of the nervous, lymphatic, or sanguine 
temperament, and this has a certain value, but a better conception of 
the physical status is to be had from a study of the physiognomy of the 
individual. Based upon embryological conditions and formulated with 
some precision by Lombroso, Dejerine, TTeismann, Fere, and others, 
we can recognize a type of degenerate or, preferably, defective individ- 
uals, from whom are largely recruited the neurotic, the insane, and the 
criminal classes. 

The marks of this type are called the stigmata of degeneracy, and 
may be divided into the morphological and the functional. 

Morphological Stigmata. — Commencing at the crown of the head, 
the whorl of hair at the vertex which normally is close to the median 
line may be widely displaced or duplicated. The cranial conformation 
is often abnormal in outline, capacity, or dimensions. The occipital 
protuberance and ridges, the frontal eminences, and the mastoid processes 
are usually excessively developed. The facial angle is reduced, the 
contour of the face asymmetrical, the lower jaw disproportionately large 
and prognathic. The hard palate is sharply vaulted, the dental arcades 
narrow, disproportionate, saddle-shaped, or angular and badly articulated ; 
the teeth defective, misplaced, with sometimes persistence of milk-teeth 
late in life. The ears are disproportionate in size, misplaced, mal- 
formed, particularly at the root of the helix, which may bifurcate, or 
the tragus and antitragus are misplaced, while the concha is crumpled 
or has a tendency to stand out widely from the head. The eyes show 
notable defects, extreme refraction anomalies, squints, different colored 
irides, and disproportionate lids and palpebral openings. Deviation of the 
nose, septal deformities, harelip, cleft palate, remnants of branchial clefts in 
the neck or in front of the ears, and the presence of other teratological 
deficiencies are frequent in this class of persons. 

On the part of the trunk, spina bifida, sacral growths of hair, deep 
sternal furrows and concavities, or disproportion between thorax and 
abdomen are to be noted. 

The Extremities. — The upper and lower limbs may be disproportioned 
to each other or to the trunk. They may be mismated in length and 
development. The hands and feet may be too small or too large. There 
is often a tendency to left-handedness and left-sided overdevelopment. 
Deformities of the fingers, such as syndactyly, Polydactyly, deviations, 
distortions, excessive length or shortness, especially undersize of the 



22 NEBV0U8 AND MENTAL DISEASES. 

ring and little fingers as compared with the rest of the hand, are 
common in degenerates. 

The genitalia in the male, besides a general lack of growth, are fre- 
quently developmentally defective, presenting hypospadias, epispadias, 
extrophy of the bladder, cryptorchidism, congenital phimosis, scrotal 
fissure, etc.; while in the female, imperforate hymen, double vagina and 
uterus, and hypertrophied clitoris and labia are not rare. 

Taken as a whole, the degenerate physique is often marked by a 
diminished stature and an inferior vigor. Many neurotic males present 
the general body conformation of the opposite sex, including sloping, 
narrow shoulders, wide hips, excessive pectoral and pubic adipose 
deposits, with a lack of masculine hirsute and muscular marking. The 
female may present masculine characteristics, and in each case the 
opposite sexuality may be further manifest in the actions, dress, man- 
ners, voice, and mental qualities of the individual. Both sexes may 
retain the physical attributes of childhood, — infantilism, — and in these 
cases the mental development is always retarded. 

On the part of the skin, albinism, melanism, and multiple nevi are 
sometimes degenerate accompaniments. A general lack of thorough 
development in the dermal structures is manifested by defective hair 
and nails and simplicity in the papillary lines of the finger-tips. 

The functional stigmata of degeneracy show themselves : (1) 
Mentally, in defective mind qualities. These vary in degree from idiocy 
to simple retardation of speech development, in aberrant mental and 
moral tendencies, among which may be enumerated destructiveness, 
wilfulness, indecency, deceit, and sometimes extreme acuteness and 
even precocity in limited fields. Genius is essentially abnormal how- 
ever valuable it may be to the individual and to the race. It is often 
attended by many of the physical stigmata of defect. 

(2) Physically, may be mentioned backwardness in walking, stam- 
mering, incontinence of urine, merycism, color-blindness, deaf-mutism, 
perverted tastes, and cravings leading to alcoholism and other stimulant 
addictions. Perversions of the genesic sense, marked by sexual crimes 
and debasing practices, are also common. Degenerates have frequently 
a lack of adaptability to their environment, and so more or less strongly 
depart from the type and tend to extinction, subjugated by the law of 
survival of the fittest. 

In estimating the various marks of degeneracy it is clear that very 
few of them, taken alone, would justify the classification of their 
possessor among the defectives, and it is true that a very great many 
of the minor stigmata may be present in a given case, associated with 
strong mental, moral, and physical attributes. All of them, from cleft 
palate to moral imbecility, are referable to defective development. 
However, in the presence of numerous indications of physical defect 
we are entitled to expect the association of their mental and neural an- 
alogues. Hence their importance to the neurologist. 

The mental condition of the patient should not be overlooked. 
Disturbances in the psychic sphere are very common in" nervous dis- 
orders and often overshadow them. Persistent depression or excitement 



THE ANAMNESIS. 23 

out of proportion to their causes, and delusions and hallucinations that 
may or may not be properly recognized and corrected by the patient, 
require close scrutiny. Especially in hysteria are we confronted by a 
train of mental symptoms, attitudes, and reactions that may easily be 
confounded with insanity or which actually carry the patient over the 
rather broad, dividing neutral ground into the realm of alienism. Loss 
of self-control, irritability, increased emotionalism, and vague or formulated 
apprehensions are the ordinary concomitants of neurasthenia and psych- 
asthenia. Many cerebral diseases produce unconsciousness. 

Sleep in nervous patients is one of the most important practical 
considerations. If it is disturbed, seek the cause, remembering that 
habits of wakefulness are easily formed. Distressing, formulated, and 
repeated dreams and nightmares are the neurasthenic's portion and the 
expression of his lowered nervous and physical tone. Somnambulism, 
nocturnal urinary incontinence and night-terrors are the common 
property of nervous individuals in childhood. Some patients find 
difficulty in falling asleep, others in remaining asleep; others are 
simply unrefreshed upon awaking. The selection of soporific remedies 
and the time of their exhibition turn upon such considerations. 

Memory. — Nearly every nervous invalid asserts a loss of memory, 
which rarely, however, exists. This mental faculty varies not only 
greatly in individuals, but is subject to great modifications in a given 
individual under different conditions of health and age. To the 
keen perceptions of a child everything is novel, is deeply imprinted 
in the mind, and is rarely forgotten. Later in life a new face or name 
is no rarity, is not sharply apprehended, and its recollection is conse- 
quently difficult or impossible. The old, in part for this reason, re- 
member their early experiences better than more recent happenings. 
In physical ill-health and in conditions of mental abstraction or intro- 
spection, as in hypochondria, hysteria, and neurasthenia, the alleged 
loss is really a lack of the mental concentration that constitutes the 
essential basis for good memory. In such cases this may be demon- 
strated by a few questions on remote personal happenings, which will 
usually be recited with extreme minuteness and detail. A loss of 
memory may embrace a certain definite period of time. TThen this 
occurs as a result of head injury or the action of some of the poisons, 
notably the carbon gases, it may extend for some time anterior to the 
cause, as well as for a period following the cerebral accident. In many 
delirious conditions the patient recalls his experience vaguely or in a 
dream-like manner. 



24 NERVOUS AND MENTAL DISEASES. 

CHAPTER II. 
THE GENERAL PHYSICAL EXAMINATION* 

Present Condition. — What has gone before prepares the way foi 
a thorough physical examination. Whenever possible, the clothing of 
the patient should be entirely removed, as study of the physical human 
outlines is most valuable. Without this step spinal deviations, chest 
deformities, lack of symmetry in the limbs, or other serious defects of 
the most important diagnostic character may escape notice. Upon 
sketch outlines of the human figure supplied in text-books and by 
dealers abnormalities of form and function may be indicated with pre- 
cision. No lesion is too slight to be overlooked, and no assertion of 
functional health is to go unquestioned. Remote conditions are not 
infrequently causal of central disturbance, and central mischief is mani- 
fested by peripheral states. The nutritive process may first engage 
attention. 

The Alimentary Tract. — The condition of the teeth in relation to 
mastication and abnormalities of position or evidence of inherited 
syphilis, the color of the gums with reference to anemia or evidences of 
metallic poisoning, such as the blue line of lead and the sponginess of 
mercury and phosphorus, can be noted at a glance. Particular atten- 
tion is to be directed to the tongue. Aside from indicating the state 
of the stomach, it may give important evidence of nervous diseases. 
The fine fibrillar twitching of general paresis and bulbar palsy, the 
tremor of alcoholism, the contortions of chorea, the lack of motility and 
atrophy in labioglossolaryngeal paralysis, and the deviation on protru- 
sion in hemiplegia are positive signs of great value. Very often the 
patient's breath furnishes information. Alcohol, various drugs, in- 
cluding mercury and some systemic diseases, notably diabetes, give 
peculiar odors to the expired air. Catarrhal and pyemic states of the 
mouth and nasopharynx are usually attended by some fetor of the 
breath. Difficulties in swallowing are very significant. Abnormalities 
of appetite for food, gastric and intestinal indigestion, constipation, and 
rectal conditions are significant in many ways. Attacks of colic, vomit- 
ing, diarrhea, and rectal tenesmus have special bearing on the condition 
of the reflex spinal centers. The condition of spleen and liver, as in 
acute and malarial infections and chronic alcoholism, may give important 
indications of constitutional and local states that have a relation to the 
nervous phenomena under investigation. Displacement of the abdomi- 
nal viscera, such as enteroptosis, is considered very important in certain 
cases. 

The Respiratory Organs. — In the nasal and pharyngeal spaces 
inflammations, new growths, or irritation zones may furnish the starting- 
point for neurotic states of the most varying nature, as hysterical sneez- 
ing, spasmodic asthma, and pronounced neurasthenia. Laryngeal and 
pharyngeal palsies and spasms require a careful topical examination. 
In the condition of the lungs and pleurcs we seek for local explanation 
of various symptoms, such as respiratory pain and oppression, costal 



THE GENERAL PHYSICAL EXAMINATION. 25 

neuralgia, continuous cough, or for the evidence of tubercular deposits, 
explanatory, perchance, of a cachexia that might otherwise be errone- 
ously referred to nervous depression. 

Circulatory Apparatus. — The condition of the heart is revealed 
only by a thorough physical examination of its position, size, action, and 
valvular competency. The condition of the arteries, patent to the eye 
in a tortuous temporal, to the finger in radial atheroma, should be still 
more extensively investigated in the femoral, brachial, carotid, and other 
superficial regions. The condition of the blood-pressure, as shown by 
arterial tension, on the two sides of the body, near the heart, and at a 
distance, is worthy of careful study. It enables one to draw analogical 
conclusions as to the circulatory apparatus of the central nerve-organs. 
The sphygmomanometer is to be employed in all cases of circulatory 
disturbance. The condition of the arteries is the best index of the real 
age of an individual. In them Aye often find evidence of a premature decay 
out of all relation to the years that have been lived. Sphygmographic 
tracings, as a method of record and precision, have their own value. The 
pulse, by its lack of rhythm, particularly by a tendency to great variation 
in its rate, depending upon slight exciting cause?, often shows the unstable 
nerve-tone of the patient or a general asthenia. Flushings, mottlings, 
local anemias and edemas are vivid expressions of angioneurotic dis- 
turbances. The blood must be examined for parasites, hemoglobin, and 
corpuscular conditions. The severe anemias have a very important 
relation to brain and spinal symptoms. A marked leucocytosis attends in- 
flammatory and purulent processes affecting the brain and spinal cord. 
The presence of cholin in the blood is frequent in diseases marked by 
degeneration of nervous tissues and in epilepsy. Of very great diag- 
nostic importance is an examination of the spinal fluid obtained by spinal 
puncture. The various bacteria associated with inflammatory processes 
may thus be demonstrated, and in degenerative conditions of brain and 
spinal cord, especially in general paresis and locomotor ataxia, a marked 
increase in the cytological contents of this fluid is almost invariably found. 
The examination of both blood and spinal fluid by the TT r assermann and 
Noguchi methods is essential in any case where syphilis is a possible 
etiological factor. 

The temperature may be greatly modified by nervous diseases. 
Organic brain-lesions may upset the balance between the therm otaxic 
and thermogenic centers, producing either a very high or a markedly 
subnormal body-heat. In hysteria a very high range of temperature is 
sometimes noted without the usual concomitants of fever. In cerebral 
hemorrhage, basilar meningitis, and brain tumor the temperature is often 
below the normal. Early in cerebral hemorrhage the paralyzed side 
presents usually a disproportionate elevation of a degree or more of heat 
over the opposite half of the body, as is shown even by axillary tem- 
peratures. The temperature of the paralyzed side later becomes sub- 
normal. Slight variations of the central normal temperature, usually in 
an upward direction, are frequently observed in pure neurasthenic 
states, while the extremities are commonly cold. 

The Integument. — From the appearance and condition of the cuta- 
neous expanse much is to be learned as to the general health of the 



26 NERVOUS AND MENTAL DISEASES. 

individual and the activity of his physical functions. The skin may 
be greatly modified by nervous maladies. In some instances the 
dermal manifestations make up the major part of the disease, or the 
dermatosis may be an associated feature of other neurotic disturbance. 
All varieties of urticaria are of frequent occurrence among the neurotic. 
Dermographia and the tache cerebrale of meningitis demonstrate the 
vasomotor irregularities. Herpes and morphea, limited to the anatom- 
ical distribution of nerves or spinal segments, as in zoster on the face, 
trunk, or limbs, declare the nervous involvement. Nevi are apparently 
related to the nerve distribution in many instances. Chains of neuromata 
are beaded along peripheral nerves with or without cutaneous discolora- 
tion. Neuralgias of long standing are frequently marked by dermal 
changes of increased or decreased nutrition, as witness the thickening of 
the skin of the face in neuralgia of the fifth cranial nerve and the subse- 
quent blanching or the actual loss of the eyebrow and hair. The neuritides, 
if of a severe grade, show dermal dystrophy as well as muscular wast- 
ing. The epithelial structures involved may take on increased growth 
if vascular stasis favor increased nutrition, giving rise to scaliness 
of the skin and increased growth of the hair and nails. More fre- 
quently atrophic changes follow ; the skin is thinned and glazed, the 
epithelium scant and poorly protective of the more highly organized 
subjacent tissue. The hair becomes dry, brittle, and sparse, and the 
nails rough-ridged and sometimes covered with overlapping scales. 
Pigmentary changes, swelling, and blue edema are not infrequent in 
hysteria. The enormous thickenings in myxedema and acromegalia are 
also due to perverted trophic control. The redness of erythromelalgia 
and the cyanotic appearance in Raynaud's disease are striking features. 

Genito-urinary Tract.— In the genito-urinary tract are found 
many conditions bearing an intimate relation, both causal and sympto- 
matic, to nervous diseases. Some of them are overlooked or unknown 
to the patient, and others receive altogether too much attention at his 
hands. A thorough clinical examination of the urine, which should be 
quantitative as well as merely qualitative, is best made from a sample 
of a carefully measured twenty-four-hour collection. It shows at once 
the eliminative powers of the organism through the important excretion 
outlet of the kidneys. A lessened output of urea, or the presence of 
albumin or sugar, give important data as to the blood-state and may 
explain grave cerebral manifestations, such as convulsions and coma. A 
very low specific gravity is noted after hysterical attacks. A large quan- 
tity of phosphates and oxalates is common to many neurasthenic condi- 
tions, and an ammoniacal urine is usual in paretic states of the detrusor 
urinse. After an epileptic attack the specific gravity and solid con- 
stituents of the urine are increased. An excess of indican is found in many 
nervous conditions attended by inefficient elimination. 

The microscope, besides giving evidence of organic disease, such as 
nephritis, pyelitis, and cystitis, may show spermatozoa from a relaxed 
control of the outlets of the seminal vesicles, but more often demon- 
strates that the deposit considered seminal by the patient is devoid of 
testicular products. 

Anuria in nephritis is of most serious import, though it may exist 



THE GENERAL PHYSICAL EXAMINATION. 27 

almost indefinitely in hysteria when associated with persistent emesis, 
whereby the uric products are vicariously ejected. 

The state of the kidneys is made out largely by the investigation of the 
urinary secretion, but the bladder and ureters are open to more proximate 
methods. The size, expulsive and retentive powers of the bladder, its con- 
tents, and the condition of its mucous lining are, in suitable cases, to be 
investigated with piecision. Loss of sphincteric control of the bladder in 
paraplegic and ataxic conditions is usual, while in meningitis, and in com- 
atose states generally, retention of urine is to be expected and provided for. 

The external genitals rarely give much information. In males preputial 
adhesions and accumulations or a long phimotic prepuce may be the 
source of irritation and the inciting cause of general nervous phenomena. 
Here, as elsewhere, any abnormal and correctable state should not escape 
appropriate attention. This is emphatically true of the deeper-lying 
generative organs in the female. Undoubtedly undue importance has 
attached to them and much ill-advised meddling has been bestowed, but 
a lack of integrity on their part should certainly engage methodical 
treatment. 

The genesic sense is usually blunted or completely destroyed in ad- 
vanced locomotor ataxia and spinal lesions which cut off peripheral 
sensation. It is reduced in all depressed physical states, whether asso- 
ciated with marked nervous phenomena or not. On the other hand, the 
genital reflex may be accentuated in lateral sclerosis of the cord, and 
priapism, unattended by increased desire, may be a troublesome feature. 
In injuries to the cervical portion of the cord, priapism is likewise 
common. 

The question of sexual irritation and overindulgence calls for more 
than ordinary thought. Excess is a matter purely relative to the indi- 
vidual and his condition at the time of indulgence. Overuse of any 
organic function is shown by persistent fatigue and irritable prostration. 
This may here furnish us a working criterion, but we are to remember 
that matters have already gone too far when the great margin of natural 
reserve power has been overdrawn and even temporary debility pro- 
duced. Thus, an amount of masturbation or sexual indulgence insig- 
nificant in a sturdy individual, is sufficient in the defective neurotic to 
induce a profound depression. 

Spinal puncture, after the manner of Quincke, is a very important 
diagnostic procedure in many diseases of the brain and spinal cord. 
The fluid so obtained may show bacteria of infection aud pathogenic 
characters ; lymphocytes and blood-cells in inflammatory and hemor- 
rhagic conditions ; spirochetes in syphilis ; marked increase in cellular 
elements, especially the lymphocytes in locomotor ataxia and general 
paralysis, and in these two conditions, the "Wassermann and Noguchi tests 
paralysis, and in these two conditions the Wassermann and Noguchi 
tests are often positive in the spinal fluid even when the blood gives a 
negative reaction. To these must be added the tests of Xonne and 
Lange. In some spinal tumors the fluid presents a very remarkable 
yellow color. In spinal and even in cerebral hemorrhage it may carry 
a decided admixture of blood. Spinal puncture is a dangerous pro- 
cedure in brain tumor, and should then be employed only with great 
caution, especially in neoplasms of basal location, owing to their tendency 



28 NERVOUS AND MENTAL DISEASES. 

to be forced down upon the medulla by the withdrawal of the spinal 
fluid support. 

The amount of intraspinal and intracranial pressure can be roughly 
inferred from the force of the escaping stream. It can be accurately 
measured by attaching glass tubing to the puncture needle and noting 
the height to which the fluid mounts in the vertical tube. 



CHAPTER III. 
THE MUSCULAR SYSTEM. 

Motility. — It is a rule with hardly an exception that nervous 
disorders are marked by errors of motility. These vary from a condition 
of slight general weakness, or paresis, to complete loss of muscular 
power, or paralysis; from slight tremor to rigid contractions. The 
character and distribution of the muscular difficulty is often of the first 
importance in diagnosis and in localizing limited lesions. 

The station, attitude, and gait of the patient, depending as they do 
largely on muscular force, control, and activity, often furnish most 
important information. The contractured, semiflexed position of the 
upper extremity and the rigid lower limb, swung en masse from the 
pelvis with dragging toe, mark the hemiplegic. The bowed and trotting 




Fig. 1.— Mathieu's hand-dynamometer fitted with detachable handles. 

gait of paralysis agitans ; the stamping and sprawling of tabes dorsalis ; 
the steppage or high knee-action with dangling feet that results from 
multiple neuritis ; the spastic, rigid, and trembling legs of paraplegia ; 
the dangle-leg of anterior poliomyelitis; the sweeping gait of hysterical 
leg paralysis, and the cerebellar stagger tell their own story. Minor 
peculiarities are no less, but rather more, important. The spinal rigidity 
and constant guarding against jars that dominate the attitudes and 
gait of the subjects of spinal injuries; the distorted features of cranial- 
nerve palsies, athetoid movements, choreic twitchings, restlessness, 
slight limps, awkwardness, attitudes of limbs, trunk, or head long or 
customarily maintained, have one and all a significance that cannot 
be overestimated. 

Reduced Motility. — For testing muscular strength numerous re- 
cording instruments are available. In the hand-dynamometer of Mat- 



THE MUSCULAR SYSTEM. 29 

hieu we have a simple means of testing the grasp, and by fitting it 
with light handles attached at either end it can be employed in various 
ways to test the muscular groups of the upper and lower extremities. 
The examiner always has in his own person a check upon the records of 
the patient. When one handle is attached to a hook in the floor, the 
lifting power of the back, the legs, or the arms is readily ascertained. 
Readings on such an instrument are of the greatest value for clinical 
records and as a means of comparison at future times. 

But without any such instrument the physician can roughly test every 
group of muscles by opposing the efforts of the patient. To examine 
flexor and extensor muscles of the wrist, elbow, and shoulder, instruct the 
patient to resist your efforts to communicate motion to the respective 
joints. The same can be done in the lower extremity with the ankle 
and the knee. The hip is tested by having the patient mount a chair, 
ascend stairs, and raise the limb to a horizontal position. Both hands 
of the examiner grasped by those of the patient as vigorously as possi- 
ble enables the physician to compare their strength. 

In hysterics and malingerers it is sometimes difficult to feel that full 
efforts have been put forth, and in other instances muscular exertion is 
inhibited by pain or tenderness. In these cases particularly, the 
muscular tests may be advantageously varied and repeated by securing 
a large number of movements, such as having the patient stand on one 
foot, rise on the toes, stoop, crouch, lift chairs, and execute other tasks 
when he is not conscious of the purpose in view. Small movements of 
the fingers are very clearly studied as the patient buttons his clothing or 
handles different objects, which may, with design, be placed in his way. 

Where the degree of feebleness is slight, it perhaps is manifest 
simply as fatigue after exertion or in walking a comparatively short 
distance. In some cases muscles which at first register considerable 
strength are rapidly exhausted by a few full contractions. In others 
initial efforts are weak, but quickly increase to a normal power, making 
it needful to always take an average of several tests. 

The limits of the paralysis or paresis must be precisely noted, whether 
confined to a single muscle or muscle group, to the distribution of a 
single nerve or group of nerves, to a single limb, to the face, to one side 
of the body. If the involvement is widespread, it will probably vary 
in degree in different regions, and this is also of importance. The terms 
monoplegia, hemiplegia, paraplegia, and diplegia are employed respect- 
ively as the face or a single extremity, the lateral body-half with the 
corresponding limbs, both lower extremities, or both sides of the body 
are involved. 

Not only is it necessary to record the strength of the muscles under 
examination, but also the manner in which they perform. For all pre- 
cise movements, complete balance of muscular action — synergy — is a 
prerequisite. If the flexors of a joint are weakened, the extensors not 
only fail to execute their function with exactness, but their strength is 
also diminished and the resulting volitional movement is weak or clumsy 
in consequence. In conditions marked by errors of sensation, especially 
by impairment of the muscular sense which gives a knowledge of the 
position of our members and enables us to estimate weight, movements 



SO NERVOUS AND MENTAL DISEASES. 

become uncertain. This uncertainty is generally exaggerated if the 
movements are not guided by the eye. Incoordination of movement 
results. This is sought for, and, if present, is demonstrated by having 
the patient, with closed eyes, touch given points, either on his own person 
or elsewhere, as by bringing the index tips of both hands together, 
touching the tip of his nose, the lobe of his ear, or the finger of the 
examiner. In the lower extremity we ask him to touch a given object 
with the point of the foot or reproduce with the other the position given 
a limb by the examiner. In making this last test it is necessary to 
avoid furnishing the patient such information as might come from con- 
tact with the bed or personal clothing. Standing with the eyes closed 
and the feet together, reducing the base of support, is often attended, in 
spinal and other nervous diseases, with swaying of the body and a ten- 
dency to fall. This constitutes static ataxia, and is known as the Romberg 
sign. It may be graphically recorded by attaching a marking-point 
to the patient's head, which traces his ataxic movements on a prepared 
surface held at the proper level. Having the patient walk backward 
with closed eyes or stand on one foot increases the ataxia. 

Incoordination may be very great, so that the blindfolded patient 
does not come within several inches of his nose in his attempts to touch 
it with his finger, and has no certain knowledge of the position of his 
limbs under the bed-covering except as he informs himself by sight. 
While standing, he may fall at once if his eyes are closed, or even reel 
in his chair. 

The following example of ataxic writing shows incoordination very 
clearly, and indicates another important test of muscular balance : 

Fig. 2.— A specimen of ataxic handwriting. 

Increased Motility. — Perhaps motility in nervous disorders is more 
frequently excessive than deficient — that is, beyond the purposes of the 
patient. Paretic conditions, too, are not infrequently associated with 
irregular and involuntary muscular movements. 

Tremors are the accompaniment of overexertion and emotion in 
health, but often become significant symptoms of nervous disturbance 
and disease. A tremor that exceeds six to the second is called rapid, 
one below that rate slow or moderate, while the amplitude of the muscu- 
lar vibration or excursion is indicated by the adjectives fine and coarse. 
Tremors occur sometimes during complete rest, as in paralysis agitans, 
or only when the involved muscles are called upon to act — the "voli- 
tional" or "intention" tremor, as in multiple sclerosis. While tremors 
may involve the entire muscular system, as is often the case in exophthal- 
mic goiter, they may be restricted to a single limb or group of muscles, 
to a single muscle, or even to a few muscle fibrils. This last constitutes 
a fibrillary tremor, or, rather, fibrillary spasm, because it is usually devoid 
of rhythm, and presents only one or a few irregular twitchings under 



THE MUSCULAR SYSTEM. 31 

the integument. They may sometimes be provoked by stroking or tap- 
ping the surface or putting the muscle into operation. 

Eshner, 1 as a result of an extended series of experiments, con- 
cludes : (1) All muscular movements are made up of a series of 
elementary contractions and relaxations, which may be appreciable as 
tremors in conditions of both health and disease. (2) The differences 
between different tremors are of degree rather than of kind — i. e., no 
form of tremor is distinctive of any one disease or group of diseases. 
(3) No definite relation exists between one form of tremor and any 
other. (4) The frequency of movement is in inverse ratio to the 
amplitude and vice versa. (5) Habitual movements are performed 
with greater freedom from tremor than unusual movements. (6) There 
is no material difference between the movements of the two sides of the 
body, except as related to proposition 5. 

In testing for tremor the patient is directed to stretch out the arms 
with the fingers extended and separated as widely as possible. The 
difficulty becomes at once apparent, or is felt as a thrill by the exam- 
iner's hand grasping the wrist or placed against the finger-tips of the 
patient. Care must be exercised not to mistake the origin of the tremor, 
as vibrations of the head and extremities may be communicated from a 
distant point. Again, tremor in the tongue and face is best shown when 
the patient, with closed eyes, protrudes the tongue vigorously for a few 
moments. Intention tremors are usually best shown when the patient 
attempts to carry a full glass of water to the lips, to write with a pen, 
or to execute other delicate coordinate movements. By means of 
registering apparatus a tracing of the tremor may be obtained in a 
graphic manner, and for this purpose the sphygmograph may sometimes 
be employed. The following specimen of writing in a case of paralysis 
agitans most clearly shows the amplitude, rhythm, and, by timing the 
effort, the rate of the tremor : 

Fig. 3. — Specimen of handwriting showing tremor of paralysis agitans. 

Spasms. — When a muscle or group of muscles contracts more or less 
energetically without the conscious intention of the individual, it consti- 
tutes a spasm, and is clonic or tonic as it is frequently repeated or 
steadily continuous. A painful spasm is usually called a cramp, though 
a facial spasm, accompanied with pain, receives the now classical desig- 
nation of tic douloureux. 

Long-continued spasm leads to contracture, a condition in which the 
muscle eventually becomes structurally shortened. Contractures follow, 
also, through natural tonus, when a muscle is for a long time unopposed 
by its physiological antagonist. Postplegic movements sometimes follow 
brain-lesions of long standing. The paralytic portions of the body 
manifest peculiar involuntary movements, which may vary from slight 
twitchings of a choreic character to the never-ceasing, purposeless activity 

lu Jour. Exper. Med.," 1897. 



32 NERVOUS AXD MENTAL DISEASES. 

shown in athetosis, where the fingers and toes work in a tentacle-like, or 
ameboid, manner. Voluntary efforts usually increase these athetoid 
movements. In hemiplegia, at times the paralyzed members duplicate 
the voluntary motions of the sound side, producing associated movements. 
They are particularly likely to occur under instinctive action, such as 
stretching and yawning, or under strong voluntary efforts with the sound 
side, as in the attempt of a right-handed, right-sided paralytic to write 
with the left hand. 

Convulsions consist of more or less widely-distributed, persisting or 
repeated spasms, associated usually with disturbed or abolished con- 
sciousness. They are symptomatic of numerous cerebral disorders, 
injuries, and intoxications. We speak of them as being general when 
the entire body is affected, or local when the convulsive movements are 
confined to a limited portion of the muscular system, as the face, hand, 
or lower extremity. Local convulsions are frequently styled Jacksonian, 
especially if marked by progressive extension to adjacent muscles, with 
tardy, slight, or no involvement of consciousness. The initial spasm or 
sensation of such fits is called the signal symptom, indicating fairly the 
cerebral center in which the muscular storm arises. Convulsions are 
tonic or clonic, as the spasms of which they are made up are long main- 
tained or frequently repeated. 

The careful investigation of a fit, and the importance attaching to its 
details, their order of appearance with all associated, precursory and 
sequential phenomena, have already been touched upon. When these 
clinical facts must be learned from lay persons even of the most intel- 
ligent character, the difficulties are often insurmountable. In some 
cases a trained medical man or a well-instructed nurse must remain with 
the patient for the purpose of getting a complete description of the attack. 

In rare cases the ordinary muscular tone is abnormally increased — 
myotonia. This gives rise to a condition analogous to a tonic spasm, 
and voluntary effort is thereby delayed, as in Thomsen's disease, and 
to a lesser degree in paralysis agitans. Hypertonus and hypotonus of 
the muscles with corresponding increase or decrease of tendon reflexes 
are presented by spinal and cerebral lesions. 

Reflexes. — In the muscular reflexes we have a series of signs which 
give information regarding both the spinal centers, and the nerve-paths 
above and below these centers. They have great diagnostic value and 
localizing importance. A knowledge of the spinal-cord segments to 
which they belong, and of the anatomical relation of these segments to 
the vertebral bodies and spinous processes, with the association of muscle 
and sensory areas, forms the basis of spinal localization. 

A muscular reflex action is the result of a peripheral stimulation 
reaching motor spinal centers and thence centrifugallv manifest in a 
contraction. Thus, in the pupil, the stimulation caused by light falling 
on the retina travels by the sensory limb of the reflex arc to the medul- 
lary center, and there calls forth energy which flows down the motor 
limb and causes pupillary contraction. A blow on the patellar tendon 
stimulates centripetally the lumbar center, and a contraction in the 
extensor muscles of the leg results in the "knee-jerk." The normal 



NERVOUS AND MENTAL DISEASES. 33 

activity of the reflexes requires not only the integrity of the center and 
both limbs of the reflex arc, but a proper association of the center and 
the higher-lying cerebral levels. Any block or interruption in either 
limb of the arc, or the destruction of the spinal center, abolishes the 
reflex. At the same time it is a general rule that pathological conditions 
interfering with the free communication between spinal center and cere- 
bral cortex tend to increase the reflex manifestations of the cord. Mon- 
akow 1 points out that in brain lesions the hypertonias and reflex excit- 
ability are more marked the nearer the lesion approaches the spinal 
cord, and Bergman 2 shows that a cortical lesion may be entirely unat- 
tended by increased reflexes. In man, however, the absolute destruction 
of all such communication — in other words, complete division of the 
cord — produces abolition of muscle reflexes below the level of the lesion. 
Sensitiveness in the part tested is ordinarily attended by an increase of 
reflex irritability, as, for instance, in rheumatism. 

Reflexes have been variously described as skin, superficial, deep, ten- 
don, muscular, and organic, — distinctions that have no especial clinical 
value. Many of them can be inhibited voluntarily by the patient, and all 
require complete passivity on his part for their proper investigation. 
Some only appear as a result of disease. As a rule, the muscle under ex- 
amination must be slightly stretched, and then the blow or passive motion, 
which suddenly increases its tension, gives rise to the reflex movement. 

The contact or threatened 
contact of any object Avith the 
eyelids or conjunctivae causes 
a palpebral reflex — the closing 
of the eye. 

A supra-orbital reflex has 
been described by McCarthy. 
It is elicited by percussing 
over the supra-orbital nerve 
either at the point where it 
emerges or somewhat higher 
up in its field, and consists of 
a fibrillary twitching of the 

orbicularis palpebrarum. It Fig . 4 .-Method of eliciting the jaw-jerk, 

should not be confounded with 
the palpebral reflex. It is absent in severe injury or disease of the 
facial and of the fifth cranial nerves. 8 

The pupillary reflex is manifest under several conditions : (1) If 
the eyes have been closed for a few moments and then suddenly opened 
in a strong light, or if in a dark room a beam of light is thrown upon 
them, the dilated pupils quickly contract. (2) The normal eye shows 
a decided pupillary contraction if focused on a near object — say, at eight 
inches — after being directed at a distance of over twenty feet. This 
latter is sometimes called the ciliary reflex. These normal reactions are 
variously modified by disease. They may be simply sluggish, they may 
be entirely absent, or they may be dissociated. In locomotor ataxia 
and in paretic dementia, when the posterior portions of the cervical cord 

1 " Gehirn Pathologie," 1905, II. Auflage. 

2 " Brain," 1910. 3 « Xeurol. Centralbl.," Sept. 1, 1901. 

3 




34 



NERVOUS AND MENTAL DISEASES. 



(!$ 



are sclerosed, the pupils usually are narrowly contracted. They then 
respond to efforts of visual accommodation only, and are quite insensi- 
tive to light. This is known as the Argyll- Robertson pupil. Rarely 
the opposite condition has been noted in other diseases. The action of 
certain drugs on the pupil, as opium and belladonna, is always to be kept 
in mind when looking for this reflex, and the eyes must be separately 
observed, as only one may be affected. The patient must not be allowed 
to close the eyes vigorously in testing for the pupillary reflex to light, as 
this act causes the pupils to dilate, though covered by the lids. In cer- 
tain conditions, when a portion, usually one-half, of the retina is blind or 
insensitive, a narrow ray of light made to fall upon this part of the optic 
nerve, by being thrown obliquely through the pupil, causes distinct con- 
traction. Wernicke first pointed out that this occurred only when the 
lesion causing hemianopsia was situated back of the geniculate bodies 
in the optic radiation or in the visual centers, and the condition is known 
as Wernicke's sign. (3) Sharp pinching of the skin on the side of the 
neck and severe pain in general cause a dilatation of the pupil. 

The jaw-jerk, or mandibular reflex, is produced best by placing a 
ruler or similar object on the lower incisor teeth while the mouth is 

partially opened, and 
striking down upon 
it with a percussion 
hammer. This is 
followed by a quick 
contraction of mas- 
seter and temporal 
muscles, and usually 
by the active closing 
of both eyes. 

The pharyngeal 
reflex is the spasmodic 
action, familiar to 
every one, produced 
by tickling or strok- 
ing with any object 
the faucial pillars or 
the walls of the 
pharynx, and some- 
times even the soft 
palate or base of the 
tongue. It is commonly absent in hysteria. Patients who have been 
subjected to much local pharyngeal treatment sometimes acquire much 
tolerance of manipulation and control this reflex completely. 

In the upper extremities there are a large number of muscle reflexes 
which may be elicited by striking on the insertion tendon after so 
placing the member that the muscle under investigation is put in 
moderate passive tension. Unless the patient completely relaxes, it 
may be quite impossible to demonstrate the reflex, and it is often diffi- 
cult to secure this relaxation even in well-intentioned persons, unless 
their attention is distracted. 




Fig. 5.— Method of eliciting the elbow-jerk. 



THE MUSCULAR SYSTEM. 



35 



9 



The various portions of the ddtoids, pectoralis major, trapezius, ser- 
ratus mo gnus, and scapular muscles may be made to react in this way 
under the percussion hammer in most persons, but are much more active 
in neurotics and in those spinal diseases marked by increased reflexes. 
M ith the arm extended and supinated, a tap at the insertion of the 
biceps causes a flexion movement at the elbow. The flexors of the wrist 
and fingers similarly respond while the extremity is in this position. A tap 
on the lower end of the radius actuates the supinator longus, giving in 
marked cases a flexion movement of 
the elbow. 

With the elbow flexed, as by allow- 
ing the arm to hang over the back of a 
chair, the triceps is actuated by a tap 
above the point of the elbow. With 
the forearm slightly pronated and the 
hand hanging, as in the usual position 
on a chair-arm. the irrist and finger 
extensors can be similarly examined. 
Of the small muscles of the hand, only 
the palmaris brevis can readily be 
brought into play in health. This is 
done by making pressure over the pisi- 
form bone and lower end of the ulna 
with the thumb and forefinger, and 
causes a grooving in the ulnar border 
of the hand just above this point. 

In some spastic cases the passive 
sharp flexing of fingers and wrist may 
develop a wrist clonus, consisting of 
rapidly repeated movements of exten- 
sion and flexion at the joint, which 
tend to persist as long as gentle ten- 
sion upon the extensors is maintained 
by the examiner. 

On the dorsiun of the trunk there 
are a series of reflexes which, below 
the scapulae, are not of much diag- 
nostic value, and which can usually be demonstrated by stroking, pinch- 
ing, or. preferably, percussing the muscular masses. Anteriorly, with the 
patient lying supine and the abdominal wall relaxed, a tap on the costal 
cartilages on either side of the xiphoid depression causes a dimpling or 
lateral movement at this point, called the epigastric reflex. A similar tap 
on the costal border in the nipple line, acting through the abdominal oblique 
muscle, produces the abdominal reflex, most noticeable at the umbilicus, 
which is promptly drawn toward the side percussed and in the oblique 
direction indicated. Sharply stroking the lateral abdominal surface 
with the nail or handle of the percussion hammer will frequently be 
found the best mode of eliciting this reflex. 

In the lower extremities we find that a series of taps along the origin 
of the great gluteal muscle, when the patient is erect or prone, are followed 




Fig. 6.— Method of eliciting the knee-jerk 
and reinforcing it by Jeudrassik's method. 



36 



NERVOUS AND MENTAL DISEASES. 



by contractions in corresponding segments of that muscle, and a tap near 
the anterior superior spinous process starts the tensor jacioe latce femoris. 
The knee-jerk, or patellar reflex, being easily examined and frequently modi- 
fied by disease, is one of the most important of the muscle reflexes. It 
is elicited generally by having the patient cross one knee over the other 
while sitting. The under limb, with the knee at a right angle, should 
support the upper, which gently rests over it with all muscles relaxed. A 
smart, quick blow with an object of some ounces' weight, as with the back 
of a thin book or the ulnar border of the hand, upon the patellar ligament 
or just above the patella, is followed by a contraction of the anterior thigh- 
muscles, causing the suspended foot to move forward an inch or two. 
A percussion hammer at least twice the weight of the one usually em- 




Fig. 7. — Method of eliciting ankle-clonus. 



ployed in chest examinations should be used in doubtful cases and 
is valuable in routine practice. If the patient is in bed, the limb 
to be examined may be lightly placed over its extended fellow, crossing 
it at the knee, and then the blow employed, or with the patient on his 
side, the knees partly flexed, the same thing may be done. When 
difficulty is encountered in securing this response, it is to be remembered 
that unless the muscles are fully relaxed the patient may inhibit the 
phenomenon, or that it may be so slight as to escape attention. If the 
patient be placed on a high chair or on the edge of a table so that the 
legs are pendent, and at the same time his attention be diverted, the jerk 
may usually at once be shown. It can also be reinforced, as described by 
Jendrassik, by having the patient grasp some object vigorously with his 
hands, or by merely clenching his hands at the time the tendon is struck. 
In children or very nervous cases this reinforcement may be secured by 
directing the patient to forcibly grasp the examiner's hand. It should 
only be considered abolished when, thus reinforced, with the limbs un- 
clothed, the eyes closed, and the unemployed hand of the examiner upon 



THE MUSCULAR SYSTEM. 37 

the rectus femoris, no response can be detected. Similar plans of rein- 
forcement are of value in testing other reflexes, and serve to divert the 
patient's attention. 

In some cases, where the reflex activity is pronounced, by pushing the 
patella sharply downward when the limb is extended a rectus reflex is pro- 
duced. If, upon continued downward pressure, a number of rhythmic 
contractions ensue and are disposed to continue, we have the rectus 
clonus' Taps over the insertions of the adductor group and over the 
tendons of the knee flexors, in cases marked by increased reflexes, produce 
corresponding muscular contractions. 

In conditions of reflex or myotatie irritability, if the knee be extended 
and the foot strongly flexed dorsally, a sharp tap on the upper and outer 
portion of the leg, over the extensors of the foot, causes a contraction of 
the calf-muscles, and this response is called thefront-tap contraction. With 
the foot in the same position, a tap upon the Achilles tendon causes an ex- 
tension of the ankle-joint. If there is doubt about the presence of the heel- 
tendon reflex, place the patient on a chair in the kneeling posture, direct 
him to grasp the chair-back firmly, make slight pressure over the ball of 
the foot to extend the tendon and use the percussor. The early absence 
of this reflex in sciatica and locomotor ataxia renders its observation 
important. The peroneal muscles likewise respond when properly 
percussed, the foot being first turned somewhat inward to put them 
on the stretch. 

Ankle-clonus or foot-clonus is tested by sharply flexing the foot dorsally 
with the knee almost extended, and consists in rhythmic movements of the 
foot upon the leg, caused by repeated contractions of the calf-muscles. 
They persist usually as long as pressure is maintained against the ball of 
the foot. Sometimes it can best be developed by having the patient, as he 
sits, place the foot beside the chair in such a way that the weight of the 
limb is supported by the point of the foot. The clonus movement then 
causes the extremity to dance. 

A paradoxical persistent contraction is occasionally found when the 
ends of a muscle are suddenly and passively approximated. For 
instance, when the foot is passively flexed on the leg, a tonic contraction 
of the anterior tibial muscles takes place. All other muscle reflexes 
are momentary, and occur under conditions of extension. 

Tickling or stroking the plantar surface gives rise usually to well- 
known contractions of a wide-spread character, known as the plantar 
reflex. They may be confined to the flexors of the toes. Instead of 
flexion the toes may sharply extend, particularly the great toe, consti- 
tuting the important toe-sign of Babinshi, found only in disordered, 
usually degenerative, conditions of the pyramidal tracts. A blunt 
wooden tooth pick or a match stick may conveniently be used in 
seeking this sign. In some it is elicited best by irritating the outer 
half of the plantar surface ; in others, by a stroke across the ball of the 
foot; and again, in others, by a stroke under the plantar arch. Oppen- 
heim elicits this reflex by deeply and forcibly drawing the handle of the 
percussion hammer or the finger ends behind the inner border of the 
tibia in the lower third of the leg. Gordon, 1 of Philadelphia, has dis- 
covered also that very deep pressure of the calf muscles will in similar 
1 "Jour, of Nervous and Mental Dis.," Feb., 1905. 



38 NERVOUS AND MENTAL DISEASES. 

cases produce an extension movement of the toes, and claims that it is 
found in cerebral lesions when the Babinski may be absent. During the 
first two years of life extension of the toe is the normal response. Bech- 
terew 1 describes an analogous reflex response found in similar cases 
induced by extending the foot at the ankle-joint and passively but 
vigorously flexing all the toes. This manipulation is followed by in- 
voluntary extension of toes, an upward movement of the entire foot, 
and in extreme cases by flexion of knee and hip. 

When the skin on the inner side of the thigh, or when the scrotum 
is sharply stroked or pinched, the corresponding testicle is more or less 
actively drawn toward the pubic arch by the cremaster muscle. This 
cremasteric reflex must not be confounded with the slow contraction of 
the dartos tunic of the scrotum, of which it is entirely independent. 

The sphincters of the bladder and bowel act reflexly upon the contact 
of any foreign body, and the destruction or serious impairment of these 
sphincter reflexes is attended by incontinence. The sphincter reflex of the 
bladder is tested by the introduction of a sound, noting the presence or 
absence of the sphincteric grasp. A finger inserted in the rectum dis- 
tinctly feels the anal sphincteric reflex, if present. Pinching or prick- 
ing the skin about the anus causes an anal reflex consisting in a pucker- 
ing of the mucocutaneous margin of the bowel outlet, and this may 
also be attended by a distinct sphincteric contraction. 

When the corona glandis penis is pinched a contraction may be felt 
by the examiner in the perineum due to contractions in the bulbo-cav- 
ernosus muscles. This is called the virile reflex, and by some writers is 
thought to be an evidence of potentia coeundi. 

In general, we may say : r irst, that tlie Argyll-Robertson phenome- 
non, Wernicke's sign, iridoplegia, ankle-, wrist-, jaw-, rectus-clonus, and 
Babinski's sign are never found in health, and are valuable objective 
signs of central disease. Second, that the abolition of the knee-jerk 
never occurs in healthy persons, and that the abolition of the sphincter 
reflexes is strongly indicative of central disease. Third, that the aboli- 
tion of the pharyngeal and plantar reflexes, with increase of others, is 
presumptive of hysteria. Fourth, that a moderate intensification of all 
reflexes frequently indicates neurasthenia. Fifth, that the abolition of 
all reflexes in a given anatomical area points to histological disease, 
either central or peripheral, in the arcs supplying those reflexes. 

It should be pointed out that in hysteria and neurasthenia there is 
sometimes a spurious ankle-clonus that may be misleading, the foot mak- 
ing only a few vibrations upon the institution of the test. In a real clonus 
the repeated contractions are confined to the muscle or group of muscles 
related to the individual movement; in spurious clonus the antagonists are 
also active to some extent. In true typical clonus the movements are 
regular and rhythmical ; in the spurious variety irregularity, inequality, 
and a lack of rhythm are observed. In the spurious condition, too, there 
is a tendency for the reflexes to be widespread, so that a tap upon one 
patellar tendon may cause both legs to respond, start the upper ex- 
tremities, or almost convulse the patient. 

Myoidema, or idiopathic nmscidar spasm, is produced in certain irri- 
1 "Neurol-Centralb.," No. 7, 1906. 



TROPHIC CONDITIONS. 39 

table conditions by sharply striking across the muscle with a ruler or 
similar instrument, causing a local contraction at the point struck, with 
a bunching up of the muscular tissue that persists from a few seconds 
to several minutes. 

CHAPTER IV. 
TROPHIC CONDITIONS. 

The significance of abnormal variations in the nutritional conditions 
of a part is at once apparent when it is recalled that the growth and 
nourishment of all the structures of the body are presided over by 
trophic centers acting through peripheral nerves. For the proper 
nutrition of skin, muscle, nerve, and bone the integrity of the trophic 
center, of its peripheral path, and of its termination is essential. In other 
words, the anterior spinal cell and its polar prolongation in the efferent 
nerve, the lower motor neuron, can not be injured or destroyed without 
correspondingly impairing the function of nutrition in its area of distribu- 
tion. All diseases, therefore, which affect the anterior spinal gray matter 
or the peripheral nerves are symptomatized by trophic changes in the asso- 
ciated parts. Further, in some local conditions of disturbed nutrition, 
where even upon minute examination of trophic cells and efferent nerves 
we can not discern any abnormality with all the means now at command, 
still we are justified by analogy in supposing some modification of this 
trophic energy, some dynamic change, some perversion of the function 
of the trophic apparatus relating especially to its center. 

It is also evident that some substances act as stimulants or depress- 
ants of the trophic centers. This is seen in the hypertrophies of acrome- 
galia and myxedema, in Addison's disease, and genital adiposity where 
there is a disordered action of certain ductless glands. Other agents, 
as perhaps lead, may have a depressing effect upon these centers. The 
blood-supply of a part and its nutrition are intimately associated. The 
vasomotor and trophic apparatus are apparently mutually dependent, 
and as a matter of clinical fact it is constantly observed not only that 
in wasted tissues the blood-supply is greatly reduced, but that in hyper- 
trophic states the vascularity is increased. 

When the trophic apparatus of a limb is involved, the various tissues 
suffer in proportion as they are highly organized. Fibrous tissue, 
cuticular epithelium, and bone are but slightly modified, though their 
growth and repair may be stopped, while the more vascular and highly 
organized muscles and nerves promptly waste. 

The Skin. — In conditions of acute trophic irritation, as in herpes 
zoster, the skin becomes injected, red, and painful, and the epidermis is 
raised in blebs or bullae filled with serum. When the condition is one 
of chronic trophic irritation, the skin may become thickened, infiltrated, 
boggy, and show an actual hypertrophy of the subcutaneous areolar 
structure. The epidermis is increased in thickness, presenting scales 
and roughness, with an increase in the growth of hair and the secretion 
of sweat. The nails become rough, striated, coarse, and grow rapidly. 
Diminished trophic energy is marked by opposite conditions. The 



40 NERVOUS AND MENTAL DISEASES. 

epidermis is thinned, imperfect, dry, and non-resisting to ordinary wear; 
the hair becomes brittle, scant, and sometimes turns gray; the nails 
grow slowly and imperfectly. The dermal envelope closely binds the 
underlying parts, loses its pliability and softness, and presents a red- 
dish, purplish, or glistening whitish appearance. 

The muscles show disturbance of trophic enervation very promptly. 
Acute poliomyelitis, or division of a peripheral nerve, is followed in a 
few hours by a muscular relaxation that is quite apparent, and in a few 
days the part looks wasted, though it may show no change on measure- 
ment. At the end of a fortnight a lessened size can be easily demon- 
strated. The sarcode elements rapidly alter and tend to disappear, 
finally leaving only the fibrous constituents to represent the muscle by 
a band of dense tissue, which shortens, gradually producing contractures 
and deformities. 

In those conditions where the process is slower, the muscle does not 
change en masse, but is gradually invaded by the atrophy and shows 
some normal fibers very late in the disease and others that may be 
actually hypertrophied. In pseudohypertrophic paralysis the muscles 
become infiltrated with fat, which displaces the muscle elements, exag- 
gerates the muscular firmness and outlines, and gives a false appearance 
of strength. 

The peripheral nerves, when cut off from their trophic centers in the 
anterior spinal gray matter, show similar degeneration. Under con- 
ditions of trophic irritation they present proliferation of their fibrous 
structures and general thickening of their trunks, with more or less 
disintegration of their nobler elements. Optic-nerve atrophy is a visible 
instance of this kind. 

The lowly organized, almost non-vascular tendons and ligaments in 
adult cases show- little change when deprived of their nerve-supply, but 
even bone itself becomes less resistant, more fragile, and somewhat 
rarified under these conditions. In children bony growth is usually 
seriously checked. 

The trophic condition of joints in nervous affections is one of great 
interest. In tabes dorsalis, and more rarely in other organic diseases of 
the brain and spinal cord, as in progressive spinal muscular atrophy and 
cerebral palsy, great changes take place in various joints. They become 
enlarged, enormously distended with fluid, and the bones disintegrate 
without any painful attending symptoms. This condition of dystrophic 
arthropathy was first clearly recognized by Charcot, and the articulations 
thus affected are often called Charcot joints. Again, arthritis of any 
character may be followed by extensive atrophy of the muscles above 
the joint, principally those of extension. This arthritic muscular atrophy 
in which the muscles waste, but conserve their electrical and reflex 
responses, is attributed to an irritant condition which arises in the 
inflamed joint. It affects the trophic spinal centers, and thence acts 
upon the nutrition of the particular muscles physiologically associated 
with that joint. It is positively known that division of the afferent path 
from the inflamed joint to the spinal center prevents the atrophic sequel. 
Decubitus. — In acute processes involving the spinal cord an acute 
bedsore sometimes appears in a few days, and may completely denude 



ELECTRICAL CONDITIONS. 41 

the sacrum. While this is favored by pressure due to the position of 
the body and moisture from the urinary incontinence that is often 
present, it may also appear independently. Gross cerebral lesions are 
similarly marked in some cases by a sloughing of the buttocks, and this 
decubitus, as in the spinal lesions, is doubtless primarily due to inter- 
ference with the trophic control, and in the case of hemiplegia affects 
the paralyzed side only. 

Acute cystitis in paraplegic states, the low resistance of the tissues 
to pressure or heat, and the tardiness of repair have a similar significance 
and add greatly to the difficulty of caring for such patients. 

Symmetrical limited deposits of fat and pigment, Raynaud' s disease, 
symmetrical scleroderma, and scleroderma in the form of striae atrophica? 
following the nerves are clearly due to trophic disturbances, and are 
classed among the trophic neuroses. 

Local conditions of trophic impairment may be a part of general ill- 
health or systemic diseases, and may in some cases be due to, but should 
not be confounded with, them. Disuse will also produce marked nutri- 
tional changes in a part, as inactivity does of the entire organism, — 
a fact to be borne in mind in relation to neurasthenics, hysterics, and 
malingerers. 

CHAPTER V. 
ELECTRICAL CONDITIONS. 

Normal muscles and nerves respond to various methods of electrical 
stimulation in a precise and uniform manner. On the other hand, dis- 
eases which modify the electrical conductivity of nerves or their muscle- 
endings and diseases which modify the electrical stimulability of muscle- 
cells produce characteristic changes in their electrical reactions when 
properly tested. These changes are of very great diagnostic importance. 
We require, for a reasonable examination of this nature, first, an in- 
duced or faradic current that can be increased from zero to a tetanizing 
strength; and, second, a constant or galvanic current of at least fifty 
volts' strength, that can also be gradually and uniformly increased or 
decreased at will or interrupted at pleasure. The first is supplied in 
many convenient and portable forms; the second, by about thirty active 
Leclanche or equivalent cells, or the constant incandescent lighting 
circuit modified by a proper rheostat. For portable purposes batteries 
of various makers containing from twenty to fifty cells are available. 
Two electrodes are needed, one presenting from nine to twelve square 
inches of conducting surface, the other fitted with an interrupting 
handle by which the operator can easily control the current, and having 
a rounded conducting surface about one-half inch in diameter. 

When using the constant current, a milliamperemeter is of value and 
for purposes of record almost a necessity. Its readings show the amount 
of current in circuit at the particular time. It is to be remembered 
that all alterations in the condition of the test — such, for instance, as 
dryness of the electrodes or of the skin of the patient — modify the 
amount of electricity requisite to secure a given response. Probably 
identical conditions cannot be secured twice in succession. All ampere 



42 



NERVOUS AND MENTAL DISEASES. 



measurement comparisons are therefore relative and approximate. Cells 
vary so much in activity at different times that to base the record upon 
the number used is futile. Where a rheostat is employed in controlling 
a lighting current of a given potential, an index scale can be arranged 
that will furnish fairly satisfactory records. 

A uniform method of making electric tests is important. The ar- 
rangement of electrodes recommended by Erb and found satisfactory in 



M. frontalis 

Upper branch of 
facial 
M. corrug. 
supercil. 

M. orbic. palpebr. 

Muscles of the f 

nose \ 

M. zygomatici 
M. orbicul. oris <, 

Middle branch of 
facial 

M. masseter 

M. levator menti 

M. quadr. menti 

M. triang. menti 

JY. hypogloss. 

Lower branch of 

facial 

M. platysma 

myoides 

Muscles of the f 

root of tongue \ 



M. omohyoideus 



N. thoracic, anter. 
(M. pector.) 




N. phrenicus 



Suprascapular 
point. (Erb's point. 
M. deltoid., biceps, 
brachial, intern, and 
supinat. long.) 



Plexus 
brachialis 



Region of central 
convolutions 



Region of the 
third frontal 
convolution 
M. temporalis 
Upper branch of 
facial in front 
of ear 

N. facialis 

N. auriculo. post. 
Middle branch of 

facial 
Loiver br. of facial 
M. splenius 

M. sternocleido- 

mastoideus 
N. accessorius 

M. levator anguli 

scapulae 
M. cucullaris 

N. dors, scapulae 



N. axillan 



N. thoracic, long. 
(M. serratus 
antic, maj.) 



Fig. 8. — Nerves and motor points in face and neck. 



all instances is perhaps the best. The large or indifferent electrode 
thoroughly moistened in warm water, with which it is also well to wet 
the skin, is applied over the sternum, where the absence of muscles and 
of much sensitiveness obviates disturbing features. The small or active 
electrode, fitted with an interrupter and well moistened, is then placed 
over the nerve or muscles to be examined, and the current allowed to 
pass (that is "made") or is interrupted (that is, "broken") as required. 
This interference, for the sake of brevity, is called the make and break 
of the constant current. 

In Health. — The nerve-trunk — as, for instance, the ulnar at the 
elbow — in a healthy person, when stimulated by a mild faradic current, 
causes all the muscles to which it is distributed to contract more or 



ELECTRICAL CONDITIONS. 



43 



less vigorously in proportion to the intensity of the current employed. 
It is to be particularly noted that upon allowing the current to pass 
the response is instantaneous, and that the muscular contraction at 
once reaches its maximum and maintains it until the current is modi- 
fied. This phenomenon attends stimulation by either the positive or 
negative faradic pole or electrode, but the negative causes a slightly 
stronger effect. 

If, now, the constant current be substituted, we notice, first of all, that 



M. triceps (caput 
longum) 



M. triceps (caput 
intern.) 



Nerv. ulnaris 



M. flexor carpi ulnaris 

M. flex, digitor. com- 
mun. profund. 



M. flex, digitor. sub 
lim. (digiti II et III) 



M. flex, digit, subl. 
(digit, indicis et 
minimi) 

Nerv. ulnaris 



M. palmaris brev. 

M. abductor digiti 

min. 

M. flexor digit, min. 

M. opponens digit. 

min. 



M. lumbricales 




M. deltoideus 

Nerv. musculocutaneus 
M. biceps brachii 
M. brach. internus 
medianus 



nator longus 
M. pronator teres 
M. flex, carpi radialis 

M. flexor digitor. sublim. 

M. flex, pollicis longus 
Nerv. medianus 

M. abductor pollic. brev. 
M. opponens pollicis 

M. flex. poll. brev. 

M. adductor pollic. brev. 



Fig. 9.— Nerves and motor points in upper extremity. 



mild currents applied to the nerve-trunk produce no response. When 
the current is sufficientlv increased it causes, only at the make and 



44 



NERVOUS AND MENTAL DISEASES. 



break, single instantaneous contractions of the innervated muscles, which 
as quickly subside. Looking closer, we notice that the contraction with 
the negative make— otherwise the cathodal closing contraction (C.C.C.) 
— is the first to appear as the current is gradually increased, that next 
comes the positive make, or anodal closing contraction (A. C. C), followed 
in turn by the positive break, or anodal opening contraction (A. O. C), 
and then, finallv, bv the negative break, or cathodal opening contrac- 
tion (C. O. C). * Further, that by the time we have C. O. C, A. O. C. 



M„ deltoideus 



JV. radialis 
M. brachial, intern. 

M. supinator long. 
M. radial, ext. long. 
M. radial, ext. brev. 



M. extensor digit, communis 

M. extensor indicis 
M. abductor pollic. long. 
M. extensor pollic. brev. 



M. inteross. dorsal. I 




triceps (caput longum) 



)M. triceps (caput ex- 
/ tern.) 



M. ulnar, extern. 
M. supinat. brev. 

M. extens. digiti minim. 
M. extens. indicis 

j- M. extens. poll. long. 



M. abduct, digit, min. 

M. inteross. dorsal. Ill 
etIV 



Fig. 10. — Nerves and motor points in upper extremity. 

will be vigorous, A. C. C. very strong, and C. C. C. produces a con- 
stant tetanic condition lasting as long as the current flows when once 
it is set up bv the make, — a condition called cathodal closing tetanus 
(C. C. T.). 

The contractions from stimulating the nerve-trunk thus in health 
appear in the following order : C. C. C, A. C. C, A. O. C, and 
C. O. C, and this indicates their intensity in a decreasing order. The 



ELECTRICAL CONDITIONS. 



45 



important point to constantly bear in mind is that the negative make 
contraction through healthy nerves is stronger than the positive, This 
fact is thus formulated: C. C. C. > A. C. C. 

In using the constant or galvanic current one must be sure of the pole 
with which he is operating. The negative pole can be readily determined 
by bringing both metal terminals into contact with a piece of wet litmus 
paper which shows the characteristic acid red color at the spot touched by 
the negative end. Or both metal terminals of the conducting cords may 
be placed in a little water. The decomposition of the water at the negative 
pole is evident in the formation of numerous fine gas bubbles. 

When the active electrode is applied over the belly of a given 
muscle, a muscular contraction is set up by the faradic current, the 
same as that produced by stimulating the nerve-trunk. If the current 
be not too strong and the electrode not too large, the effect may be 
limited to the given muscle, or to a portion of a muscle. Every' mus- 
cle may also be actuated by the galvanic current by applying the active 



iV. cruralis 

N. obturator 
M. pectin ens 

M. adductor magnus 
M. adduct. longus 

M. cruralis 
M. vastus interims 



M. tensor fasciae latse 



-rjg — M. quadriceps femoris 

~S — ' M. rectus femoris 




M. vastus externus 



Fig. 11.— Nerves and motor points in lower extremity. 

pole on the point corresponding anatomically to the entrance of its 
motor nerve. A familiarity with motor points is of practical importance. 
They are shown in the accompanying diagrams. Slight variations in 
their location are common, and several trials are often required to find 
them. It is well to mark with a lead-pencil the necessary points, 
if repeated tests are to be employed. The galvanic polar responses 
are, in healthy muscles, identical with those obtained through the nerve- 
trunks. 

In Disease. — Diseases changing the nutrition and structure of the 



46 



NERVOUS AND MENTAL DISEASES. 



lower motor neuron, which consists of the spinal cell-body and its periph- 
eral projection and termination in muscular tissue, alter not only the 
trophic conditions over which the neuron presides, but also interfere with 
its electric properties. If the spinal cell be destroyed, or its peripheral 
filament divided, degeneration follows below the lesion, in both the nerve 
and muscle, with loss of voluntary control. The reactions of such a 
nerve and muscle to electricity are modified in a highly characteristic 



M. gluteus maximus 



Nerv. ischiadicus 

M. biceps fern. (cap. long.) 
M. biceps fern. (cap. brev.) 



N. peroneus 
gastrocnem. (cap. extern.) 

M. soleus 
M. flexor hallucis longus 




M. adductor magnus 
M. seraitendinosus 
M. semimembranosus 



N. tibialis 



M. gastrocnem. (cap. int.) 



M. soleus 



M. flexor digitor. comm. longus 



N. tibialis 



Fig. 12.— Nerves and motor points in lower extremity. 

manner. They present the reaction of degeneration (R. D.), the presence 
of which is an indubitable sign of structural change. At the end of 
about a week, during which there has been a gradual decrease of electric 
excitability in the muscle and nerve to both faradic and galvanic shocks, 
four differences become manifest : 

First. The muscle responds weakly, sluggishly, and deliberately to fara- 
dism, and shows a tendency to maintain the contraction after the 
current is withdrawn. This is the modal change. 
Second. The nerve-trunk loses progressively and equally its responsive- 
ness to both galvanism and faradism— a quantitative change. 



ELECTRICAL COXDITIOXS. 



47 



Third. The muscle becomes much more excitable by galvanism and 
much less excitable by f aradism, which latter reaction with the nerve- 
trunk responses is completely lost after two or three weeks. This is 
the qualitative change. 
Fourth. A polar change appears in the muscle about the second week 
when directly stimulated by galvanism. It is now found not only 
that the muscle is more readily caused to contract by the constant 
current, but that the normal mastering strength of the negative 
closing contraction over the positive has disappeared and that the 
positive closing contraction is equal to or greater than the negative. 
Expressed thus : A. C. C.= or > C. C. C. Anodal tetanus (A. T.) 
is often obtained. This polar difference continues until the nerve 
either regenerates and regains its normal status, or, failing to recover, 
gradually the galvanic irritability subsides. It is entirely abolished 
with all other electrical responses in complete degeneration. 
Should recovery take place, the restitution is marked ordinarilv, first, 
by a return of voluntary control, then, by the appearance of galvanic 
and faradic excitability in the nerve, and, last of all, by faradic excita- 
bility of muscle. The hyperexcitability of the muscle to galvanism and 



M. tibial, antic. 

M. extens. digit, comni. 
long. 



M. peroneus brevis 



M. extensor ballueis 
long. 



Mi. interossei dorsales 




Nerv. peroneus 



M. gastrocnem. extern. 
M. peroneus longus 



M. soleus 



M. flexor hallucis long. 



M. extens. digit, comm. 
brevis 



M. abductor digiti min. 



Fig. 13. — Nerves and motor points in lower extremity. 

the polar variations from the normal gradually right themselves at the 
same time. These changes and the pathological process in nerve and 
muscle are shown in the diagrams (Fig. 14) modified from Erb. 

In some cases we find a partial reaction of degeneration, the nerve- 



48 



NERVOUS AND MENTAL DISEASES. 



trunk response being only slightly modified. The inverted polar formula 
is not necessarily present. The most essential element in the reaction 
of degeneration is the modal change, — the slowly appearing muscular 
response, — so at variance with the instantaneous effect produced in health. 
Next in importance is the lessened faradic control of the muscle, and, last, 
the polar modifications. The variations in the galvanic and faradic 
responses in disease are due principally to the fact that currents of a 
certain strength and duration are required to actuate the changed sarcode 
cells, and the rapidly interrupted faradic current thereby becomes 
inoperative. The galvanic current, if interrupted with sufficient rapid- 
ity, is equally powerless. 

In some conditions is found a simple increase or decrease of electrical 
excitability, constituting a pure quantitative change. In those diseases 



Gali/amc— 






= P 



ar&che 



s_ J Galvanic 
<w „ a-n.a 




^j GaJv&me. 
j§[fa.mcHc 



Health 



"Degeneration. 
°>Herve 



/ftrdjAu** fWiferationof Hluscle, jgrrkggs fe&aL 




mmdt 



Fig. 14.— 1, Paralysis with early return of motion (modified from Erb). 2, Incurable paralysis with 
complete atrophy aud degeneration (modified from Erb). 



where the muscles seem permanently affected, as in the progressive 
atrophic myopathies, the responses are reduced, but are proportionate to 
the amount of healthy muscular fibers remaining. Some spasmodic con- 
ditions, like facial tic, present an increased activity to electric stimulation. 
There is increased electrical excitability in tetany and in Graves' dis- 
ease. In myotonia we encounter a peculiar electrical response called 
the myotonic reaction. In this condition there is normal faradic ex- 
citability of nerves, but the electrical excitability of the muscles is 
greatly enhanced to all forms of current. The positive and negative 
closing galvanic contractions are nearly equal and all responses are tonic 
and prolonged. The mechanical excitability of the muscles, as to 
blows, is similarly exaggerated. In myasthenia gravis the muscular 
responses are rapidly exhausted by repeated stimulation with faradism 
or galvanism. They gradually lose force as the stimulus is repeated, 



SENSORY CONDITIONS. 49 

and in a few moments fail completely, but reappear after a short rest. 
This peculiarity is called the myasthenic reaction. 

The use of electricity to test cutaneous sensation is open to so many 
errors and attended by so much difficulty that simpler means, always at 
hand, are to be preferred. In those feigning complete cutaneous anes- 
thesia the surprise of a strong, painful, faradic current from a dry, metal 
electrode will be likely to unmask the deceit. 

When the active electrode is placed over the closed eye or at the 
temple, the make or break of constant currents is attended by a subjective 
sensation of light, and this test serves to show the activity of the retina 
and optic nerve. By placing the indifferent electrode on the same side 
of the neck, one eye at a time may be examined, and for this purpose 
only small currents — from two or three cells or of as many milliamperes 
— should be used. In the same way either auditory nerve may be tested 
by placing the active electrode over the mastoid or before the tragus, 
the negative pole producing much the louder sound. 

For testing the nerves of taste the galvanic current is a prompt and 
reliable agent. By those of keen perceptions a difference between the 
positive and negative pole can be distinguished. For the ordinary 
purpose of taste testing, electrodes ending in probe-pointed metal 
terminals, or even the metal ends of conducting cords held to the tongue 
or pharynx, at once give rise to an acid or salty taste, which is quickly 
appreciated by the patient. One or two cells are all that is required, 
and one side of the tongue can be easily compared with the other in 
lateral lesions, or the tongue of a healthy individual will furnish a 
standard when needed. 

For the purpose of localizing the various muscular areas in the motor 
zone of the cerebral cortex when it is exposed, surgically or otherwise, 
a mild faradic current is used. It may be applied to the brain surface 
by means of a wire or pointed metallic electrode, the other pole being 
attached to a broad sponge placed over the sternum. It is best applied 
by a double probe electrode, which limits the faradic action to a definite 
area. Such a current thus applied causes, in the related muscular per- 
iphery, similar responses to those produced by faradizing the nerve-trunk, 
but the movement has more of a purposive or gesticulatory character. 
These responses also follow an extradural application of the electrode. 



CHAPTER VI. 

SENSORY CONDITIONS. 

Modifications of sensation are among the commonest conditions 
attending nerve-lesions and functional disturbance of the neural appa- 
ratus. It is well to have a prefatory understanding of the fact that 
sensation, of whatever variety or quality, is due to the appreciation of 
temporary motion and contact, or, in simpler terms, that all sensations 
are modifications of touch. It is the impact of luminous and sound- 
waves on properly qualified nerve expansions that gives rise to sensations 
of sight and hearing. The contact of odorous and sapid particles stim- 
ulates the sensations of smell and taste. The recognition of the va- 



50 XERVOUS AXD MEXTAL DISEASES. 

rious qualities of objects in contact with the skin gives us information of 
size, shape, temperature, hardness, smoothness, and a thousand physical 
properties of the external world. 

Another general consideration is that any overstimulation of sensory 
nerves is painful. That which is so readily called the pain sense is but 
the subjective recognition of this overstimulation coupled by instinct 
and experience with the concept of harm. Thus the contact of a sharp 
point is at first so recognized and the sense of pain comes when the pres- 
sure is increased and the stimulation intensified. It can not be doubted, 
however, that pain and thermic sensations have courses in the spinal cord 
separate from tactile impressions. Extremes of heat, cold, pressure, 
noise, light, odors, and tastes give rise to pain or to discomfort analo- 
gous to pain. They cause automatic or conscious efforts of avoidance 
and self-preservation. It is also a matter of common experience that 
sensations, except of an extremely painful character, if long maintained, 
are more or less completely ignored. Therefore, to elicit sensation the 
motion or contact must be temporary or repeated after distinct intervals. 
Clothing to which we are habituated gives rise to little or no conscious 
sensation. With the long persistence of an odor there is a gradually 
diminishing perception of it. On the other hand, the sudden stopping 
of a clock or other familiar and disregarded sound is almost startling. 

In considering the various qualities and modifications of the sense of 
touch it is requisite to bear in mind that keenness of sensibility varies 
greatly not only in different cutaneous areas in a given subject, but con- 
siderably in different individuals. The more keen, active, and intelli- 
gent the make-up of the subject, the quicker and more precise are the 
responses. To all tests of sensation the disadvantage pertains that we 
are dependent upon the responses of the person tested ; so that such tests 
are only partly objective. Sudden extreme pain, however, is usually 
attended by certain recognizable signs, such as change of countenance, 
quickened pulse, dilated pupil, pallor, and even perspiration. To carry 
out the needful tests we require the intelligent cooperation of the patient, 
and to this end he must understand exactly what is sought. In order 
that his replies may depend upon his receiving information through the 
tested source alone, the eyes should be bandaged or other suitable pre- 
cautions taken to prevent their use. The tested parts should be com- 
fortably placed and supported and all distracting conditions, such as 
noise or talking, avoided. Check tests must also be used, such as asking 
"what is felt?" when nothing is applied, or by using some indifferent ob- 
ject in place of the one which the patient is expecting, as the finger-tip 
instead of the pin point, requiring him at the same time to tell what it is. 

The attending conditions must be usual and natural. It is useless to 
test the sensibility of chilled extremities or to expect reliable replies 
from the stuporous. In many instances, moreover, there is much sensory 
disturbance without the patient being aware of it, as in hysteria; or 
there may be a dissolution of the various qualities of the sense of touch 
that has not specially attracted his attention, as in syringomyelia. ^ 

The tactile sense enables us to recognize the contact of objects with 
the skin. In a crude way its delicacy may be tested by stroking with 
a feather or flake of cotton, by touching lightly the ends of hairs grow- 



SENSORY CONDITIONS. 51 

ing on the limbs, or by ruder contacts when the sense is found blunted. 
An instrument called an esthesiometer, consisting of two movable points, 
is frequently employed in testing this element of the sense of touch. A 
pair of compasses answers the purpose. Observations are made as to 
the least distances at which two blunted points are both recognized when 
brought into contact with the skin at the same time, and in a line parallel 
to the course of the nerve supplied to the part. These distances vary 
widely, as between the tip of the tongue or finger and the dorsum of the 
body. The following average measurements will serve as a standard of 
comparison, or if the sensory disturbance be limited to one side of the 
body, the opposite corresponding area will furnish a better guide. Dif- 
ferences, to be significant, must be about double those here indicated : 

Table Showing Okdinary Distances at which Two Points ake 

Recognized. 

Tip of tongue .... 1 mm. (1-25 in.) Tip of toes, cheeks, eyelids . . 12mm. 

Tip of fingers . . . . 2 " Temple 13 " 

Lips 3 " Back of hands 30 ' l 

Dorsal surface of fin- Neck 35 lt 

gers 6 " Forearm, leg, back of foot . .40 " 

Tip of nose 8 " Back 60-80 " 

Forearm 9 " Arm and thigh 80 ll 

Another means of testing the tactile sense is to place variously- 
shaped objects on the skin and to ask a description of them, or to trace 
letters and numerals with a blunt point. The so-called stereognostic 
sense is a complicated faculty, embracing many or all of the elements 
of tactile sense. All those perceptions of the qualities of an object 
received through the sense of touch make up a complex enabling its 
recognition if repeated with sufficient frequency. Thus we can with 
closed eyes recognize by touch all familiar objects. In certain brain- 
states, particularly those involving the sensori-motor cortex, and perhaps 
in a more limited sense the parietal area, the faculty is lost, constituting 
a state of astereognosis or, better, stereoagnosis. 

The pain sense may be readily investigated by using a pricking point, 
but it must not be too fine. A pointed quill or toothpick answers well 
except in marked analgesia. The patient is required to state whether a 
touch or a painful prick is recognized. If the part examined be hairy, 
pullimg on a few hairs with the fingers or a forceps elicits a sense of 
pain very effectively. 

The pressure sense, which is not of great importance, is tested by 
placing on the skin objects of the same size and external character, such 
as balls of e'qual size but variously weighted. A spring instrument 
fitted with an index and a scale is also used. Where the extremities are 
thus tested it is necessary to so support them that no notion of the pres- 
sure be given by motions communicated to the joints and muscles. 

The thermic sense can be quickly, though roughly, examined by 
first breathing on a part with the mouth only an inch away and then 
blowing upon the same part from a distance of twelve inches. In order 
to estimate it more exactly it is best to use test-tubes filled with water 
at various known temperatures. Every test requires that considerable 
surface come in contact with the skin for a few moments, as the integu- 



52 



NERVOUS AND MENTAL DISEASES, 



Auriculotemporal 3 V. 

Great occipital 

Lacrimal 1 V. 

Temporomalar 2 V. 

Small occipital C. P. 

Great auricular C. P. 



Supraclavicular 
C. P. 
Acromial branch 
Middle branch 



Circumflex B. P. 
Interoostohumeral 

Nerve of Wrisberg 

B. P. 
External cutaneous 
of musculospiral 
B. P. 

Internal cutaneous 
B. P. 



Musculocutaneous 
B. P. 




Branches from external 
popliteal S. P. 



Musculocutaneous S. P. 

External saphenous S. P. 
Anterior tibial S. P. 



Supra-orbital 1 V. 

Supratrochlear 1 V. 
Intratrochlear 1 V. 
Nasal 1 V. 

Infra-orbital 2 V. 
Buccal 3 V. 
Mental 3 V. 

Superficial cervical C. P. 



Sternal branch 



Anterior branches of intercostal 
nerves 



Lateral branches of intercostal 
nerves 



Iliohypogastric L. P. 
Dorsalis penis of pudic S. P. 
Ilioinguinal L. P. 

Genitocrural L. P. 
Middle cutaneous L. P. 
Intern*).! cutaneous L. P. 



Internal saphenous L. P. 



Fig. 15.— Cutaneous distribution of nerves (after Flower). 



SENSOBY CONDITIONS. 



53 



Great occipital, posterior branch or 
second cervical 



Third cervical 



Posterior branches of spinal nerves 



Lateral branches of intercostal nerves 

Iliac branch of ilio-inguinal L. P. 
Second lumbar 

Inferior hemorrhoidal of pudic S. P. 

Superficial perineal of pudic and 
inferior pudendal of small 
sciatic S. P. 

Interior gluteal of small sciatic S. P. 



Internal cutaneous L. P. 



Internal saphenous L. P. 



Auriculotemporal 3 V. 
Small occipital C. P. 

Great auricular C. P. 




Supraclavicular 
— C. P. , acromial 
branch 
Second dorsal 

Circumflex B. P. 



Intercostohumeral 

Internal cutaneous 

of musculospiral 

B. P. 
Nerves of TYrisberg 

B. P. 
External cutaneous 

of musculospiral 

B. P. 

Internal cutaneous 
B. P. 

Musculocutaneous 
B. P. 



Radial B. P. 
Ulnar B. P. 



External cutaneous L. P. 



Branches from external 
popliteal S. P. 



External saphenous S. P, 



Posterior tibial S. P. 



Fig. 16.— Cutaneous distribution of nerves (after Flower). 



54 NERVOUS AND MENTAL DISEASES. 

merit must gain or lose heat proportionately before the exact degree 
of temperature is appreciated. Within a few degrees of the ordinary 
body surface-temperature — namely, 80° to 86° F. — slight changes are 
not recognized in health. Below this to freezing and above it to about 
150° F. a variation of two to five degrees is readily perceived. Inability to 
recognize temperatures from 60° to 70° as cool and 86° to 100° as warm 
may be considered abnormal. Such a condition is denominated thermo- 
anesthesia, and, when complete, thermo-analgesia. Those parts of the skin 
possessing the most acute tactile sense are also most sensitive to heat. 

The term muscular sense is used in two ways : 

First. It refers to the sensations arising in muscles themselves. In 
a painful degree this occurs in a cramp or in a tetanizing faradic con- 
traction. The tension on muscles and tendons is no doubt subconsciously 
recognized by the coordinating mechanism, and it is only when these 
sensations are greatly intensified that we take conscious note of them. 

Second. By muscular sense we refer to the ability to estimate the 
weight of various bodies. This ability is to so great an extent a result of 
practice and varies so widely among healthy persons that unless great 
differences of weight are not appreciated the test gives little information 
of value. Balls, such as those employed in the pressure test, can be 
used, or attempts made to repeat a fixed number on the dynamometer. 
When the sensation of tendons, joints, and muscles is blunted, not only 
is the muscular sense reduced, but knowledge of the position of the 
limbs is wholly or in part wanting and ataxia is present, as described 
under Errors of Motility. 

In certain conditions, notably tabes, sensation is retarded and the 
reaction time is greatly prolonged. A painful impression, as by the 
prick of a pin on the foot, may not be recognized and responded to for 
several seconds. In such cases the transmission of all touch sensations 
may not be equally slow. We prick the patient, having instructed him to 
say "now" as soon as he feels the needle, and we note the interval, 
which, in health, is a small fraction of a second only. The intelligence 
and promptness of the patient materially affect the apparent length 
of intervening time. Under this test the patient may promptly recog- 
nize the contact, but only after a distinct interval of time does he experi- 
ence the feeling of pain. In some instances a single prick is recognized 
as two or more, or a painful impression is felt at a distant point, — a 
referred sensation, — or on the opposite side of the body at a symmetrical 
spot, — allocheiria. 

The sensibility of bones and joints may be roughly but readily tested 
by resting the stem of a vibrating tuning-fork at those points where they 
are subcutaneous. Normally one perceives the communicated thrill. 

Complete loss of sensation is properly termed anesthesia. Through 
usage this word signifies any degree of blunted sensation, and is qualified 
by adjectives such as partial, complete, or slight, as the case may require, 
and further limited by such combinations as muscle anesthesia, tactile, 
thermic, and joint anesthesia. The loss of the sense of pain is called 
analgesia, and this word is compounded in a similar way. 

A most painstaking study of the varieties and relations of the ele- 
ments making up general sensibility has been made by Head, who for 



SENSORY CONDITIONS. 55 

the purpose had the cutaneous nerves of his own forearm surgically 
divided. 1 From his observations it is evident that superficial and 
deeper sensibilities follow different afferent fibers, and are gathered into 
a comparatively simple complex higher up. He says : " The sensory 
mechanism in the peripheral nerves is found to consist of three systems : 

" (I) Deep sensibility, capable of answering to pressure and the 
movement of parts, and even capable of producing pain under the influ- 
ence of excessive pressure or when the joint is injured. The fibers sub- 
serving this form of sensation run mainly with the motor nerves, and 
are not destroyed by division of all the sensory nerves of the skin. 

"(II) Protopathic sensibility, capable of responding to painful cuta- 
neous stimuli, and to the extremes of heat and cold. This is the great 
reflex system, producing a rapid, widely diffused response, unaccom- 
panied by any definite appreciation of the locality of the spot stimulated. 

" (III) Epicritic sensibility, by which we gain the power of cuta- 
neous localization, of the discrimination of two points, of very light 
touch, and of the finer grades of temperature, called cool and warm." 

Sensation may be intensified, giving rise to hyperesthesia and hyper- 
algesia. These conditions are made evident by the usual tests, and 
require no extended review. 

In addition there are a host of purely subjective sensory disturbances, 
described as sensations of heat or cold, numbness, prickling, crawling, 
creeping, tingling, heaviness, deadness, etc., — paresthesia?. Areas so 
affected may show no alteration of sensibility when actually tested. 
Paresthesia? usually are symptomatic of general nutritional states or of 
the so-called neuroses. 

Having determined a localized dysesthesia, or condition of disturbed 
sensation, it is of the first diagnostic importance to outline it as accu- 
rately as possible. Sensation may be disturbed by lesions which involve 
sensory paths at any point from the cerebral cortex to the terminal 
organs in the muscles and skin. The dysesthesia area, however, presents 
a different and distinctive outline as various nerve-levels are injured. 

If a nerve-trunk or branch be injured by traumatism or disease, 
anesthesia will be limited to the corresponding anatomical cutaneous 
distribution. Per contra, if such anatomical area be found to be anes- 
thetic, the inference is at once justified that a peripheral lesion is 
present. As soon as the sensory nerve-fibers reach the spinal cord they 
ramify so widely in the various segments that it would be impossible for 
any spinal disease or injury to select a given number from all others. Fig^ 
ures 15 and 16 show these sensory areas, and should be carefully studied. 

If the spinal cord undergo a complete cross-lesion or division, we 
have loss of sensation in the nerve-area below the upper level of the 
injury. Now, the distribution of anesthesia has relation to the cord- 
segments, and not to the nerve-trunks. For a practical understanding 
of this fact it is necessary to recall that the body, from one end of the 
vertebral chain to the other, is made up of a number of similar seg- 
ments or links, all more or less perfectly represented in the skeleton, 
muscles, viscera, skin, and nervous apparatus. In the dorsal region the 
plan is comparatively simple, but as the limbs are reached it is greatly 

i " Brain," 1905 and 1908. 



56 



NERVOUS AND MENTAL DISEASES. 



complicated. If vertical sections of the body were to be made approx- 
imately on these segmental lines, it would be requisite to place it in the 
all-fours position, making the coccygeal end of the vertebral column the 
posterior or last segment. The diagrams of Starr (Fig. 17) clearly show 
this, and the difference between the spinal-segment area and the nerve- 
trunk representation of sensation is apparent. It at once becomes plain, 
when we find an anesthetic area corresponding to a spinal-segment level 
that the lesion is in the cord and at a particular part of the cord ; more- 
over, that its upper level corresponds to the upper level of the anesthetic 
zone. Just above this level, owing to the irritation of the sensory roots 
of the spinal nerves, there commonly is a band or girdle of hyperesthe- 
sia bordering the anesthetic area. This also serves to indicate the upper 
limit of the spinal lesion. 

Should the cord injury involve only one lateral half of the trans- 
verse cord-section, the symptom complex of Brown-Sequard paralysis 
develops. The hemicordal lesion causes complete loss of power on the 



avi 




a vi 



a vi 



a vi v cvni 
a vii 



, ~ VT C.VI . 

l.iii. ^"M CVI avn 
<v- a vii 

c- 




a vi 

< v a vii 



Fig. 17.— Cutaneous areas related to the spinal-cord segments (Starr). 



same side as the lesion in all parts below that point. There is also 
usually a slight loss of power below the lesion upon the opposite 
side. Anesthesia is complete on the side opposite the lesion, below 
its level. This is due to the fact that the sensory paths, upon 
entering the cord, cross to the opposite side, and then proceed up- 



SENSORY CONDITIONS. 



57 



ward. The sensory roots entering the cord at the point of lesion 
are destroyed; so that there is upon the same side of the body a band 
of cutaneous anesthesia which marks the exact level of the lesion of the 
cord. It varies vertically in relation to the extent of cord destroyed. 
The sensory roots entering the cord at the upper margin and at the 
lower limit of the lesion, irritated thereby, furnish, both above and below 
the band of anesthesia, a varying band of hyperesthesia on the paralyzed 
side. On the opposite or anesthetic side there is also a band of hyper- 
esthesia due to the irritation of the sensory root as it crosses into the 
contralateral half of the cord at the upper 
level of the destructive process. This sen- 
sitive area is always a little below the hyper- 
esthetic band of the paralyzed side. The 
accompanying scheme (Fig. 18) shows the 
sensory tracts and the involvement of the 
sensory roots upon each side. The distri- 
bution of sensory and motor disturbance is 
shown in figures 18 and 19. In addition, 
the reflexes are increased below the lesion 
on the paralyzed side, but abolished at the 
level and throughout the vertical extent of 
the lesion. 

Lesions of the internal capsule involving 
its posterior sensory portion give rise to 
hemianesthesia embracing more or less accu- 
rately and completely one-half of the head 
and trunk with the limbs on the same side. 
It is usually associated with similarly dis- 
tributed motor paralysis. 

In the cerebral cortex cutaneous sensory 
representation is related quite closely to the 
motor fields, but is not identical with them, 
being placed mainly just behind the strictly 
motor territory. Cortical lesions in this field 
lead to paresthetic disturbances of sensation 
that have functional rather than anatom- 
ical limits, just as electrical stimulation of 
the cortex leads to purposive or grouped 
muscular movements, and not to those sub- 
served by any spinal segment or nerve- 
trunk. In hysterical anesthesia a similar 
distribution is noted, the affected area often 
having the outline of the surface covered 
by a glove, sock, or sleeve, and limited with 
precision to the functional area that is the 
object of the patient's attention or solicitude. 

Pain as a symptom is worthy of careful study. The first inquiry 
should be as to its character. Is it constant or intermittent ? is 
it periodical? does it appear at a regular time daily, or every other 
day, or is it worse at any particular time of the day ? Then, is it 




Fig. 18. — Scheme representing 
cord-lesion and effects in Brown- 
Sequard paralysis (after Brissaud). 
CSG, Left sensitive tract ; CSD, right 
sensitive tract; A, B, C, D, lesion 
involving the left half of the cord ; 
S, S, S, sensory roots from right side 
of bodv ; Z, Z, Z, sensory roots from 
left side of body ; Z*, Z\ and S- are 
irritated only at the points A, B, C, 
and their peripheral area is hyperes- 
thetic; Z 2 is divided and its skin 
area is anesthetic on the same side 
as the lesion. Corresponding to S 1 
and all the roots below arising from 
the right side of the body, there is 
anesthesia. 



58 



NERVOUS AND MENTAL DISEASES. 



sharp, lancinating, or dull and heavy? Note exactly the distri- 
bution of the pain. Observe if it is limited to the cutaneous area of 
a peripheral nerve or if it has the distribution of a spinal segment. 
In every instance of pain, seek for tenderness. The painful part, during the 
presence of protracted pain, is almost invariably sensitive. When lightly 
touched, certain portions of the hyperesthetic surface will be found 
especially affected. These maximal points of pain are usually situated 
where the sensory nerves become superficial or pass bony prominences. 

It is best to carefully outline these sensitive areas with a blunt 
point, as the head of a large pin, and not trust to the rough gestures and 
statements of patients. In other instances the tenderness can only be 
detected by deep pressure. For instance, intercostal neuralgia produces 

superficial tenderness ; pleurisy 
is marked by tenderness on deep 
pressure or percussion. To Dana 
and Head 1 we owe a definite 
knowledge of the relation of 
cutaneous sensitiveness and pain 
to visceral disease. Head's w T ork, 
abundantly verified, clearly shows 
that the superficial surface of the 
body is in relation with the vis- 
cera through the spinal centers. 
Disease arising in the visceral 
portion of a vertebral segment 
gives rise to pain referred to the 
body or somatic area. Similarly, 
disease of the spinal segments 
gives rise to pain and other 
sensory disturbances in the skin, 
as already pointed out, and in 
the associated viscera. Macken- 
zie 2 insists that the viscera are 
insensitive and that pain is fell 
through the cerebrospinal nerves 
alone. That, for instance., the 
well-known tenderness over the liver readily elicited by pressure in disease 
of that organ is in fact confined to the skin and muscles of the abdominal 
wall. These areas, as mapped out by Head, with their maximal points 
for the body and limbs, are presented in figure 20 (A, B, C), and the 
following table shows the relation of the viscera to these areas : 




Fig. 19. — Application of the scheme to the trunk 
(Brissaud). Anesthesia is indicated by horizontal 
lines ; hyperesthesia by diagonal lines. 



Table Showing Aeeas of Pain Keferred feom Visceral Disease. 

Heart — First, 2d, 3d, dorsal segments. 
Lungs. — First, 2d, 3d, 4th, 5th dorsal. 
Stomach. — Sixth, 7th, 8th, 9th dorsal ; cardiac end from 6th and 7th. 

Pyloric end from 9th. 
Intestines. — (A) Down to upper part of rectum. 

Ninth, 10th, I lth, and 12th dorsal. 
(B) Rectum. 

Second, 3d, and 4th sacral. 



: Head, "Brain," Ivi. 



2 " Brain," 1902. 



SENSORY CONDITIONS. 



59 



x- st- x. ^^- k <* 




RjRjCjRj 







q q q q & 




£j q q q q 



<J h 



60 



NERVOUS AND MENTAL DISEASES. 



Liver and Gall-bladder. — Seventh, 8th, 9th, 10th dorsal. 

Perhaps 6th dorsal. 
Kidney and Ureter. — Tenth, 1 1th, and 12th. The nearer the lesion lies to the kidney, 
the more is the pain and tenderness associated with the 10th dorsal. The 
lower the lesion in the ureter, the more does the 1st lumbar tend to appear. 
Bladder. — (A) Mucous membrane and neck of bladder. 
First, 2d, 3d, 4th sacral. 
(B) Overdistention and ineffectual contraction. 
Eleventh and 12th dorsal and 1st lumbar. 
Prostate.— Tenth, 11th, 12th dorsal. 

First, 2d, 3d sacral and 5th lumbar. 
Epididymis. — Eleventh and 12th dorsal and 1st lumbar. 
Test's.— Tenth dorsal. 
Ovary. — Tenth dorsal. 

Appendages, etc. — Eleventh and 12th dorsal and 1st lumbar. 
Uterus. — (A) In contraction. 

Tenth, 11th, 12th dorsal and 1st lumbar. 
(B) Os uteri. 

First, 2d, 3d, 4th sacral, and 5th lumbar very rarely. 

A further point elucidated by the same author is the relation of head 
pains and aches to visceral disturbances. Such pains and aches are 
marked by definite areas of sensitiveness when at their height and by ten- 



FRONTONASAL 



Maxulary 
Nasolabial 



Superior Laryngeal 
Inferior Laryngeal 




Fig. 23. 
Figs. 21, 22, and 23. — Maximal points of referred and associated pain on the head and face. 



SENSORY CONDITIONS 



61 



der maxima. These maxima, as those upon the trunk, are practically 
the tender points of Valleix. They are much more persistent than the ten- 
der areas, which usually are only well marked when the pain is severe 
and gradually subside concentrically, leaving the maxima. On the head 
and face, as on the trunk and limbs, these pain-areas have segmental dis- 
tribution and in no manner correspond to the peripheral nerve-supply. 

Figures 21, 22, and 23 show the cephalic maximal points, and the 
following table shows the relation of the body- viscera to these head- 
points and also to the body-areas : 

Table Showing Associated Painful Aeeas on the Head Related to 
Visceeal Disease in the Body. 



Area on Body. 


Associated Area on 
Scalp. 


Organs in Particular Relation to 
these Areas. 


Cervical, 3 


Frontonasal (? ros- 
tral). 


Apices of lungs. Stomach. Liver. 


Cervical, 4 


Frontonasal. 




Dorsal, 2 


Midorbital. 


Lung. Heart. Ascending arch of 
aorta. 


Dorsal, 3 


Midorbital. 


Luug. Arch of aorta. 


Dorsal, 4 


Doubtful. 


Lung. 


Dorsal, 5 


Frontotemporal. 


Lung. Heart. 


Dorsal, 6 


Frontotemporal. 


Lower lobe of lungs. Heart. 


Dorsal, 7 


Temporal. 


Bases of lungs. Heart. Stomach. 


Dorsal, 8 


Vertical. 


Stomach. Liver. Upper part of small 
intestine. 


Dorsal, 9 


Parietal. 


Stomach. Upper part of small intestine. 


Dorsal, 10 


Occipital. 


Liver. Intestine. Ovaries. Testes. 


Dorsal, 11 


Occipital. 


Intestine. Fallopian tubes. Uterus. 
Bladder. 


Dorsal, 12 


Occipital. 


Intestine. Uterus, etc. 



In like manner disease within the head and neck has its referred pain, 
associated tender area, and maximal point. They may be thus tabulated : 



Organ at Fault. 



Maxima of Pain 
and Tenderness. 



Organ at Fault. 



Maxima of Pain and 
Tenderness. 



Ciliary muscle (errors 

of accommodation) . 

Cornea ....... 

Iris 

Vitreous (glaucoma) . 

Eetina 

Teeth (upper incisors) . 
Upper canine and first 

bicuspid 

Upper second bicuspid 

Upper first molar . . 
Upper second and third 

molars 

Lower incisors, canine, 

and first bicuspid . 
Lower second bicuspid 



Midorbital. 

Frontonasal. 

Fronto-temporal . 
Temporal and 
maxillary. 

Temporal. 

Vertical. 

Frontonasal. 

Nasolabial. 
Temporal or 

maxillary. 
Maxillary. 

Mandibular. 

Mental. 
Mental or hvoid. 



Lower first and second 

molars Hyoid and pain in 

the ear. 

Lower third molar . . Superior laryngeal. 

Membrani tympani . Hyoid. 

Middle ear Vertical and behind 

ear. 

Tongue, tip Mental. 

Tongue, lateral part . In ear and hyoid. 

Tongue, base .... Superior laryngeal. 
Occipital. 

Tonsil In ear and hyoid. 

Nose, olfactory portion Frontonasal and 
midorbital. 

Eespiratory portion 
and posterior nares . Nasolabial. 

Larynx Superior and infe- 
rior laryngeal. 



62 NERVOUS AND MENTAL DISEASES. 

Brain disease presents pain of two varieties : First. When the men- 
inges are involved there is a local pain with tenderness on pressure and 
percussion. Second. In conditions of intracranial pressure and disease 
of the brain proper there is superficial tenderness and the pain is widely 
distributed over the head. In the second class of cases pain is usual in 
the brow, vertex, occiput, back of the neck and shoulder, and similarly 
distributed tenderness is common. 

The descriptions of some pains by patients are classical and almost 
diagnostic. The lightning pains of tabes, the gnawing pains of rheu- 
matism, the burning pains of neuritis, the girdle pains of spinal disease, 
the lead-cap pressure pain of neurasthenia, the pain under the breast 
and in the groin in hysteria, the daily recurring brow pain of malaria, 
and the nocturnal pains of syphilis have a significance quite their own. 
The circumstances under which pains occur often throw light upon their 
nature. Sciatica and lumbago are provoked by motion and allayed 
by rest. The head pains of eye-strain bear a distinct relation to ocular 
employment. Neurasthenic pains always increase under fatigue or de- 
pressing — that is, exhausting — emotions. A pain that is practically 
circumscribed has a tendency to spread to associated organs and to 
neighboring areas after long duration, general depression, or the onset of 
any marked physical illness. It thus becomes generalized. 



CHAPTER VII. 
THE SPECIAL SENSES, 

Sight. — The eye presents many interesting and valuable symptoms 
in a wide variety of nervous affections. Its systematic examination 
should be a part of the case-taking in every instance. 

The lids on the two sides may show a difference in the palpebral 
opening due to paralysis or spasm. Exact symmetry is the rare excep- 
tion in health, but any marked acquired inequality, unless due to scars 
or local conditions, such as conjunctivitis, irritation, swelling, new 
growths, etc., implies some variation of muscular control or nerve-supply. 
A falling of the upper lid, or ptosis, is a common early symptom of tabes 
and syphilitic brain disease, while in a facial palsy an inability to close 
the lids is a marked sign. From the same cause the lower lid may be 
everted. An acquired prominence of the eyeball may greatly enlarge 
the palpebral opening. In exophthalmic goiter the lids frequently fail 
to follow the upward and downward excursion of the ocular globe. This 
is not entirely due to the protrusion of the eye, as it has been noted in the 
absence of this condition, and in some instances is congenital. In hysteria 
a condition often confounded with ptosis, but really an orbicular spasm, is 
sometimes encountered. Blepharospasm as a limited facial tic is a very 
common affection. Many states of brain and optic-nerve disturbance are 
marked by the closed lids of photophobia, which should not be confounded 
with that arising from inflammatory conditions of the lids, cornea, or iris. 

Attention has already been directed to the reactions and reflexes of 
the pupils. In all examinations of the pupils the observer must ex- 



THE SPECIAL SENSES. 63 

elude the actions of those drugs, like opium, cocain, and belladonna, 
which modify their size and reactions. Irregularities in their outline 
or inequalities in size are to be carefully noted, but pupillary deformi- 
ties from antecedent inflammatory processes or injuries followed by 
synechia must not be mistaken for perverted innervation. Inflamma- 
tion of the pleura, 1 apical tuberculosis, and pneumonia may cause 
either narrowing or widening of the corresponding pupil when tested 
by ordinary daylight. Paralysis of the pupillary muscles is iridoplegia; 
paralysis of the ciliary muscles — cycloplegia — is marked by the loss of 
the function of visual accommodation. They are usually found 
together, and then constitute ophthalmoplegia interna. Paralysis of the 
external muscles of the eye — namely, the recti, obliqui, patheticus, and 
the elevator of the lid — is denominated ophthalmoplegia externa. 

The external muscles receiving their innervation from three sources, 
the third, fourth, and sixth cranial nerves, are very frequently involved 
singly or in groups. This gives rise to various deviations of the visual 
axes of the eyes or loss of power in directing them conjointly in some 
given direction, with resulting indistinctness of vision or complete double 
vision, — diplopia. Rarely a monocular diplopia is encountered as a 
pure hysterical symptom, but it may be the result of defective curva- 
tures in the ocular media, as in corneal deformities. The special 
examination to determine the muscle or muscles at fault in these squint 
conditions will be taken up under the consideration of the diseases of 
the cranial nerves distributed to the ocular apparatus. Great and un- 
warranted stress has been put by some enthusiasts upon a condition of 
a lack of balance among the extrinsic muscles of the eye, named hetero- 
phoria. Of much greater importance are errors of refraction and ac- 
commodation in myopia, hyperopia, and astigmatism. They are attended 
by conscious or unconscious efforts at clear vision, constituting a condi- 
tion of eye-strain that may furnish an active source of nerve waste. 
Extreme and constant deviations from the normal control of the extrinsic 
eye muscles can, no doubt, act in the same way, but slight variations in 
conditions of ill-health are commonly the result and not the cause of 
such states. As the general state fluctuates, they correspondingly vary 
for better or worse. 

Vision can be readily tested by the types of Jaeger, and when seriously 
defective, by having the patient count fingers held in a good light against 
a dark background. Astigmatic error is roughly and quickly shown by 
the use of the numerous familiar charts for the purpose. For further 
details reference should be had to systematic works on the eye. 

The ophthalmoscope is one of the most important instruments in the 
diagnostic outfit of the neurologist. An ability to readily examine the 
ocular fundus at the bedside or elsewhere is one of his most needful 
accomplishments. Familiarity with the normal ophthalmoscopic picture, 
supplemented by experience in recognizing vascular disturbances, choked 
disc, and atrophy of the optic nerve, will often render positive a host of 
otherwise obscure indications. The characteristic appearance of the 
fundus in diabetes and Bright 's disease and the choroidal changes of 
syphilis are valuable signs. 

1 Chauffard, "Arch. Gen. de Med./' Mar., 1905. 



64 



NERVOUS AND MENTAL DISEASES. 



The visual field is the area over which objects are visible while the 
eye is fixed. In health its limits are tolerably uniform, being modified 
above and within by the brow and nose. In this field colors of objects 
are recognized by the normal eye at various distances and in a certain 
order from the fixed point upon which the gaze is directed. From 
without inward come white, blue, yellow, orange, red, green, and violet. 

The form of the test-object is perceived before its color is apparent, 
as is shown by the chart (Fig. 24). 




Fig. 24.— Normal visual fields for form and the various colors (after Souques). Form field unshaded. 
The blue field is inclosed thus , the red field thus + + + +, the green field thus 1 1- 



The visual field is peculiarly modified by various diseases. In pro- 
nounced hysteria we have usually a concentric uniform reduction of the 
field. The color-fields may be reduced almost to the fixing-point or 
entirely obliterated. Even more characteristic is a rearrangement of 
them so that the red field overlaps or completely surrounds the blue. 
The relation of red and blue is therefore to be remembered. Cushing 
and others have found contraction, inversion, and interweaving of the 
visual color fields rather common in brain tumor cases, and not appar- 
ently dependent upon the extent or duration of the usually attendant 
choked disc. In neurasthenia the fields are frequently much reduced, 
and fatigue conditions promptly increase their contraction. In well- 
marked cases the efforts put forth by the patient in responding to the 
tests may serve to greatly increase the reduction of the fields within a 
few minutes. In tobacco and alcohol ptoisoning and other toxic con- 
ditions the fields are sometimes greatly contracted and present irregular 
blind areas, or scotomata. Destructive diseases occurring back of the 
globe may cut off a portion of the field, producing hemiopia, scotomata, 
central blindness, concentric blindness, or blindness in a quadrant of the 
field, as the fibers or centers related to the given area are involved. 

To test the field of vision a perimeter is of service, and, for accurate 
examinations and records, indispensable. Roughly, it can be done by 



THE SPECIAL SENSES. 65 

placing the patient opposite a fixed point on a bare black or dark wall, 
at a fixed distance of eight to twelve inches. With one eye covered he 
is ordered to maintain his gaze unswervingly on the fixed point. A 
small white object, preferably about a centimeter in diameter, is brought 
into the field from the periphery along various lines radiating from the 
fixed point, and the spot marked at which it is first perceived by the 
patient. By joining a series of such points the outline of the field is 
constructed and the various color limitations are similarly defined by 
noting the distances at which the color of the test-object is clearly 
recognized. Large blind spots may in this way sometimes be detected, 
the test-object being carried across the field to the fixing-point. The 
normal blind spot corresponding to the optic papilla must not be mis- 
taken for a symptom of disease. More roughly still the field can be 
rapidly tested by facing the patient at a distance of about two feet. He 
is then directed to look you steadily in the eye opposite the one to be 
tested ; that is, if the patient's left eye is under examination, he looks 
at the examiner's right. A small object is brought into the field of 
view in a plane midway between the patient and physician, and the dis- 
tance at which it is seen is noted. At the same time the examiner's 
own perception furnishes a check and measure to the test. 

The subjects of Daltonism, or color-blindness, are congenitally defective 
in color perceptions. Some have complete achromatopsia, everything to 
them being probably of a neutral tint ; others do not distinguish some 
elementary colors, as red from green ; and others, again, fail to detect 
marked shades of the same color. This defect would modify tests of 
color-fields accordingly. 

Hearing. — The sense of hearing is most often modified by local 
conditions in the meatus and middle ear. Our usual problem is to de- 
termine whether the nerve-apparatus is impaired. To this end we note 
at what distance on either side the patient can hear a watch, remember- 
ing that in advanced years such high-pitched sounds are not heard so read- 
ily as lower tones, like those of the voice. If the watch is not heard 
through the air, the ear should be closed by pressing in the tragus with 
the finger and the watch brought into contact with the root of the 
zygoma, the mastoid process, the parietal bone, or the teeth. If it is 
now heard, the difficulty is presumably in the conduction apparatus, and 
not in the nerve. This can be confirmed by using a tuning-fork in 
Binne's test. Set it in vibration and place the handle against the 
mastoid or zygoma, the meatus being closed. When no longer heard, 
unstop the ear and hold the still vibrating fork close to it. The nor- 
mal ear will detect tones through the air that do not reach it by bone- 
conduction, but if there be obstruction in the external or middle ear, the 
bone-path will be the more acute. The formula is B. C. > A. C. or 
B. C.=A. C. If there is no recognition of high or low tones by bone- 
conduction, the nerve-apparatus is undoubtedly diseased, or if with hear- 
ing greatly reduced A. C. > B. C. is still found, the probability is that 
the nerve is diseased. 

Auditory hyperesthesia is occasionally encountered in acute cerebral 
meningeal conditions and in hysteria. Severe headaches, meningitis, and 
5 



66 NERVOUS AND MENTAL DISEASES. 

many cerebral affections are marked by dysacousia, — sounds producing 
discomfort, — which may or may not be attended by real auditory hyper- 
esthesia. In the relaxation of the tensor tympani muscle attending facial 
palsy low notes are heard with unusual distinctness, while those of high 
pitch may not be so clearly perceived as in health. 

Subjective sounds, varying from an insignificant tinnitus to pronounced 
and formulated auditory hallucinations or loud explosions in the head, 
are referred to with great frequency by nervous invalids. Their starting- 
point is not rarely in the external or middle ear or Eustachian tube. Irri- 
tation of the auditory centers and nerve, however, is sometimes the cause. 

Involvement of the labyrinth or of its nerves is marked usually by 
vertigo, and in extreme cases by forced movements in a given direction, 
which, as in Meniere's disease, may furnish attacks of great sudden- 
ness, throwing the patient to the ground. The space sense with equili- 
bration is disturbed. (See also p. 136.) 

Finally, in no case of obscure brain symptoms should the possibility 
of extension of infection from suppuration in the middle ear and mas- 
toid be forgotten, — a condition that specular examination and local 
searching commonly reveal. 

Smell. — The sense of smell may be reduced or obliterated in one 
or both nostrils. It is necessary to test them separately, closing firmly 
the opposite anterior naris. The inspiratory efforts should not be too 
vigorous, as thereby the test odor may reach both nasal spaces through 
the pharynx. In selecting the test-material, pungent odors or irritants, 
such as ammonia or tobacco-snuff, should not be employed. In hysteria 
anesthesia of the mucosa may be associated with absence of the sense of 
smell, so that the strongest irritation gives rise to no response ; other- 
wise, when the olfactory nerve is completely destroyed, stimulants and 
irritants have their usual effect. It is also well to choose an odor 
with which the patient is familiar, and to recollect that people vary 
greatly in keenness of scent. The sense of smell is greatly impaired 
by nasal catarrhal trouble, and is often practically lost during a severe 
cold in the head. Degeneration of the fifth nerve, which supplies 
common sensation to the nasal mucous membrane, also lessens its 
acuteness. 

Occasionally the sense of smell is greatly intensified. Hallucinations 
of smell are rare, and in several cases have been found to depend upon 
disease in the temporosphenoidal lobe. 

Taste. — Pure taste sensations are the recognition of bitter, sweet, 
sour, and salt. When a taste is associated with an odor, we speak of a 
flavor, and it requires the participation of the olfactory nerve, usually 
stimulated by way of the posterior nares. Flavors, in consequence, are 
lost with the loss of smell, and not with the loss of taste. The margin 
and tip of the tongue are more sensitive to sours and salts, while the 
base and pharyngeal pillars best recognize bitter and sweet. The en- 
tire gustatory area, which includes the dorsum of the epiglottis and even 
a portion of the rima glottidis, as well as much of the pharyngeal wall, 
distinguishes all tastes more or less readily. 

For the purpose of testing taste, solutions of sugar, quinin, citric acid, 
and salt, or the powdered substances, answer. The tongue should be 



SPEECH. 



67 



protruded and the test-substance applied to a small area. Some moments 
are usually required before the taste is perceived. The galvanic electric 
current furnishes a simple and reliable agent. Two probe-pointed 
metallic electrodes a few millimeters apart are placed on the portion of 
the tongue to be tested, and a non-painful current from one or two cells, 
of a few niilliamperes' volume, is used. A metallic taste is elicited. 

Taste is lost from the tip of the tongue in lesions of the facial nerve 
involving the chorda tympani. Hemiplegic states rarely show a one-sided 
loss of taste, while the hemianesthesia of hysteria, when pronounced, is 
usually marked by ageusia on the same side. 

Perversions of taste — parageusia — and increased sensitiveness — 
hypergeusia — are sometimes encountered in neurotics and hysterics. 
Subjective taste sensations are also rare, but may furnish the aura of an 
epileptic attack in the so-called uncinate fits, or be dependent upon 
local irritation of the trunks of the nerves of taste, as in ear disease 
affecting the chorda and facial nerve. 



CHAPTER VIII. 
SPEECH. 

There are as many kinds of speech as there are avenues to con- 
sciousness and routes therefrom. We have spoken language, written 
and printed speech, gestures and emotional attitudes that portray thought 
and serve as media for the communication of ideas. Consequently, 
speech may be modified by disease in innumerable ways as the successive 
levels of the nervous system are invaded, and every variety of speech 
may be disturbed either in its perceptive or emissive channel. 

The emission of vocal speech requires mechanically the coordinate 
action of the mouth parts, the larynx, and the chest-muscles of respira- 
tion. Malformations of the nose, throat, mouth, and larynx are attended 
with difficulty in shaping the resonant chamber for the precise modifica- 



Physiological Table of Consonants. 





Voiceless Oral 
Consonants. 


Voiced Oral 

Consonants. 


Voiced Nasal 
Eesonants. 


Labials 


P 




B 
W 


M 


Labiodentals 


F 




V 








Linguodentals 


Th 

s 




Th 

Z 

■ 




Anterior linguopalatals 


Sh 
T 


Zh 
D 

L 

E 


N 


Posterior linguopalatals 


K 

Hor 


Ch 


? 


Ng 



68 NERVOUS AND MENTAL DISEASES. 

tions of vocal sounds in the production of spoken language. Cleft-palate, 
closed nasal spaces, and tied-tongue are not uncommon conditions of this 
variety. They cause difficulty mainly in the pronunciation of the con- 
sonant sounds. If we are familiar with the physiology and mechanism 
of consonant production, we have the key to diagnosis. 

For this purpose the preceding chart, slightly modified from 
Wyllie, 1 is of great importance. He divides consonants into voice- 
less and vocal, as their pronunciation is or is not devoid of laryngeal 
sound. By having the patient pronounce these letters, or phrases con- 
taining them, the seat of the difficulty is at once recognized. For in- 
stance, in the palatal palsy of diphtheria the posterior linguopalatals and 
the nasal resonants, especially Ng, which depend on the separation of the 
nasal spaces from the pharynx by the soft palate, are slurred or lost. 

Stammering, or stuttering, is a speech defect attended by difficulty 
in attacking properly the enunciation of words beginning with certain 
consonants. These consonants are reiterated with more or less spasmodic 
respiratory effort, and finally the word either drops out or is explo- 
sively spoken. There is always more or less incoordination in the 
needed muscular combinations. 

Speech in idiots and infants often consists of the iteration of a sylla- 
ble or single sound {lolling) or the repetition of the final word or phrase 
overheard by them, without reference to its meaning, — echolalia. In mul- 
tiple sclerosis the speech becomes deliberate and each syllable is pro- 
nounced with the distinctness of scanning. In general paresis the words 
are jumbled. The patient catches in the middle of words, repeats sylla- 
bles, slurs sounds, and omits terminals or even important words. This 
is called syllable stumbling. In hereditary ataxia the speech shows the 
incoordinate control of the musculature of vocalization and is usually 
slow, monotonous, and unmodulated. In cerebral palsies with athetosis 
speech may be characteristically modified by the spasmodic actions of 
the muscles of the tongue, throat, and chest. It is explosive, sputtering, 
now slow, now fast, and the tone qualities are uncontrolled. In hysteria 
persistent aphonia is a frequent symptom, a whispering voice only re- 
maining. Complete mutism may also develop slowly or suddenly in this 
malady, but voice sounds, as in coughing or sneezing, usually remain to 
show the neurotic character of the disturbance. In progressive bulbar 
palsy the paralysis of the tongue is early marked by indistinctness of 
speech and a loss of the lingual consonant sounds. If the lips are 
weakened, the labials can not be produced, and, finally, through paralysis 
of the tongue and larynx, vocal speech is reduced to inarticulate noises. 

In diseases marked by tremor, as in alcoholism, Graves' disease, and 
paralysis agitans, the voice is also tremulous. Depression, excitement, 
and the emotions generally are manifest in the timbre and modulation of 
the voice. The deaf are inclined to speak in a monotonous, high, or 
more often low, tone that is quite peculiar to them. 

Aphasia. — Organic disease of the brain, throwing out of operation 
the various cortical centers related to speech or breaking up their con- 
necting channels, produces peculiarly interesting phenomena that require 

1 "Disorders of Speech," Edinburgh, 1894. 



SPEECH. 69 

very careful examination. Any of the qualities or varieties of speech 
may be affected, or almost any combination of defects may be present in 
a given case. Practically we have to investigate both spoken and written 
speech and to determine first how they are received and apprehended, 
and, second, how conceived and expressed. In other words, we try to 
determine whether the difficulty lies in the entrance-channel or the 
receptive center on the one hand, or in the formulating center and the 
emissive route on the other. 

Take, first, the reception of spoken speech. Is the hearing good, tested 
by watch, tuning-fork, voice, and various sounds? If so, does the 
patient understand the words used ; or is he word-deaf- — that is, while 
hearing words does he fail to appreciate their meaning ? Test this by 
directing him to execute certain movements — to shut his eyes, clap his 
hands, etc. 

Second, how does he produce spoken speech f Is it reduced to a 
single expletive or phrase, or is he completely dumb ? Does he forget 
names of common objects (amnesia verbalis), stammer, slur, stumble, or 
reiterate ? Does he miscall objects with which he is familiar (paraphra- 
sia), and is he aware of his mistakes ? Is his speech a jargon of mean- 
ingless sounds or words strung together like beads ? If dumb, can he 
write his answers? and if he can not write, can he indicate with his 
fingers the number of syllables in the names of objects pointed out to 
him ? Finally, can he repeat or echo what is said to him, or is he 
inclined to echo his own words or expressions ? does he understand 
his repeated words ? 

Written Speech. — If vision is good, does the patient understand 
written or printed questions ? This can best be determined by writing 
simple commands, as, stand up ! sit clown ! give me your hand ! and 
not by questions that can be answered by a nod. Proper responses 
show comprehension. If the written questions or commands are only 
partially understood, we must attempt, by repeated tests, to decipher the 
limitations of his alexia. Secondly, does he write ? If agraphia is not 
present, does he use wrong nouns (paragraphia), repeat letters or words, 
or make serious omissions ? Can he write from dictation and from 
copy, and does he then understand what he thus writes ? 

When other speech avenues of the mind are blocked or only partly 
obstructed, the recognition of gestures, their use and repetition, should 
be noted. Some patients do not make gestures (amimia), or employ 
wrong gestures in attempting to explain themselves (paramimia). 

To some patients objects have lost their meaning, so that familiar 
things and intimate friends are not recognized, — a condition called mind- 
blindness. The sense of touch (stereognosis) may still furnish informa- 
tion to the mind that has lost its recognition of visual impressions, so 
that a piece of money or familiar object unrecognized by sight may 
be correctly named when placed in the hand, though this faculty is 
also commonly defective when there is mind-blindness. 

The handwriting, especially with the pen, in many cases furnishes 
diagnostic evidence of great value, as well as a means of studying the 
progress of the disease. A hand-magnifier will often bring out peculi- 



70 NERVOUS AND MENTAL DISEASES. 

arities that are not readily seen by unaided vision, and for the same 
purpose photographic enlargement may be used. When abnormalities 
are slight or only suspected, a specimen from something written several 
months or years previously will serve as a proper basis for comparison. 
Appropriate allowances for youthful growth or the decrepitude of age 
must be made. The education, habitude of writing, and physical con- 
dition at the time are also to be considered. As a rule, in health the 
down strokes are made with more strength, precision, and rapidity than 
the other written lines. If they show inequalities, tremor, waves, or 
marked angularities, the significance is greater than the appearance of 
these anomalies in the upward lines or connecting curves. The signing 
of the patient's name, for those who write it frequently, becomes quite 
automatic, and often fails to fairly show the character of the disturb- 
ance. It is well to dictate some ordinary sentence, to have the patient 
copy a paragraph from a newspaper, or write a little account of his ill- 
ness. Many times it is only after writing a few minutes that the diffi- 
culty manifests itself. This is particularly true in writers' cramp. In 
general paresis the first of a letter page may be well, firmly, and co- 
herently written, the latter part showing tremor, inequalities, omitted 
words, and incoherence. Blots, spatters, and wavering lines demonstrate 
the ataxia of the patient. The aphasic shows his cerebral lacunae by 
using wrong words, by writing jargon, and by the repetition of letters, 
syllables, and words or phrases when not intended. 

• The loss of complex motor activities, such as agraphia, motor aphasia, 
amimia, and professional or skilful motor combinations, is denominated 
apraxia, and may be present without attending paralysis of the corres- 
ponding muscular organs. 

■ Mirror-writing is a variety in which the letters are formed back- 
ward, like printers' type, and appear properly when viewed in a re- 
flecting surface. Left-handed children often write thus naturally, and 
it has been noticed in hysterics and degenerates. Rare cases of mirror- 
speech have been recorded, in which words were inverted by syllables or 
literally. 

Varieties of handwriting are given in the description of the various 
diseases which present such peculiarities. 

Fig. 24a. — Mirror writing spontaneously produced by a five-year-old left-handed child. 

Finally, photography furnishes a most valuable adjunct to case-taking 
when any peculiarity of conformation, attitude, gait, or facial expression 
is observed. Serial photographs vividly present the course of the dis- 
ease. The use of a case-book, properly prepared, is of the utmost value 
to systematize the examination and secure a full but concise record. 
The form given on page 71 may serve as an outline, requiring to be 
properly spaced for actual use. 



SPEECH. 



71 



Name 

Residence 

Occupation 

Health History 



Foem foe Neubological Case-book Page. 

Nationality 

Civil Condition 



Age 

Heredity. 



Date ...._ 

Children 



Injuries 

Habits 

Present Illness 



PRESENT CONDITION. 


Alimentary System 


Eyes 


Circulatory System 




Respiratory System 


Lids 


Tegumentary System 


Pupils 


Genito-urinary System 


Movements 


Pulse Temperature Weight 


Vision 


General Appearance 


Field 


Attitude 


Fundus 


Gait 






Ears 


Motor Condition 


Deformities 




Hearing 




Sense of Smell 


Sphincters 


Mouth 




Lips 


Sensory Conditions 


Tongue 
Palate 




Articulation 


Subjective 


Voice 


Objective 


Aphasia 


3Iuscular 


Deglutition 


Delayed 


Taste 


Thermic 




Diminished 


Brain 


Intensified 




Pain 


Memory 




Logical Powers 




Emotions 


Electric Conditions 


Consciousness 




Vertigo 




Sleep 




Spinal Cord 


Trophic Conditions 






Superficial Reflexes 




Deep Reflexes 




Coordination 


Diagnosis 


Spinal Column 


Treatment 


Handicriting 



PAET II. 

DISEASES OF THE CEREBRAL MENINGES AND 
CRANIAL NERVES. 



CHAPTER I. 



THE CEREBRAL MENINGES— PACHYMENINGITIS AND 
PIAL HEMORRHAGE. 

Anatomical Considerations. — The coverings of the brain are 
admirably suited to protect it from injury and infection. Guarded ex- 
ternally by the skull and the scalp-pad, it is intimately enveloped by the 
dense, fibrous dura mater in a practically sealed sac. The usual anatom- 
ical descriptions of the cerebral meninges are misleading. Ordinarily 
three distinct membranes are named and described, when in reality there 
are but two. Lining the skull we have the dura mater, serving as an 
internal periosteum for the cranial bones and furnishing in part their 
vascular supply. It is entirely free from the brain, but gives off sheaths 
to the cranial nerves and the large vessels at their exit from the skull, 
and supplies venous channels or sinuses for the return circulation of the 
encephalon. The dural fold between the cerebral hemispheres and the 
tentorium cerebelli afford support and protection. 

In normal conditions the brain fills the cranial cavity fully, and its 
soft covering membrane is everywhere in contact with the inner surface 
of the dura. The interval which separates them is called the subdural 
space. No actual space, however, exists, the two membranes being 
smoothly applied to each other and only separated by disease or mechan- 
ical means. 

Closely investing the brain is the pia mater, made up of two layers 
or membranes very loosely attached by delicate meshes of fibrous tissue. 
The outer can be easily stripped from the under layer, and constitutes 
what is usually described as the arachnoid. The alleged double layers 
and spaces of the so-called arachnoid can not be demonstrated and do 
not exist. This outer pial layer we may call the arachnopia. Between 
it and the under layer, or visceral pia, is a varying space, the pial space, 
filled with a delicate, open, reticular network of fibrous tissue containing 
cerebrospinal fluid or lymph. It is an enormous lymph-space. At the 
gyral grooves the visceral pia dips to the bottom of the sulci. It 
everywhere closely adheres to the brain-cortex, which it follows 

72 



PACHYMENINGITIS AND PIAL HEMORRHAGE. 



73 



through the transverse fissure into the ventricular chambers, furnishing the 
velum interpositum and bearing the choroid plexuses. The arachnopia 
bridges over the sulci. This arrangement at the great fissures and at 
the base of the brain in the intervals between the cerebrum, cerebellum, 
and medulla forms lymph-reservoirs, which are continuous with the pial 
spaces of the spinal cord through the foramen magnum. Delicate proc- 
esses of the pia also accompany the cranial nerves and vessels from the 
skull, and are continuous with the extracranial lymph-channels. 

Between the pial layers the cerebral vessels ramify. As they pene- 




Fig. 25.— Diagram of cerebral meninges and cortex. D, dura mater ; S. D., subdural space; P. S., pial 
space; A. P., arachnopia; V. P., visceral pia; X, arterial perivascular space; Z, venous perivascular 
space (Tuke). 

trate the cortex both arteries and veins are accompanied by deli- 
cate sheaths of the visceral pia, which form the perivascular lymph- 
spaces of the brain. Some of the great pyramidal cells of the cortex 
are encapsuled by diverticula from these perivascular lymph-channels, 
and are thus nourished (Tuke). In a manner, therefore, these most 
important cortical elements may be considered as appendages of the pia, 
with which they have such intimate anatomical relations. The pia also 
pushes up the Pacchionian bodies into the vascular area of the dura 
near the venous sinuses at the vertex. These bodies are supposed to 
furnish an outlet for the meningeal lymph. 

The brain is constantly changing in bulk through variations in vascu- 



74 NERVOUS AND MENTAL DISEASES. 

larity due to mental or physical activity. This would be impossible 
were it not for the ready displacement of the cerebral fluid. Losses of 
brain-substance by atrophy or otherwise are mechanically compensated 
in bulk by an increase in the pial fluid and the hydrostatic balance is 
preserved. It is probable that the entire pial surface participates in the 
production and absorption of the cerebrospinal fluid. The wide rami- 
fications of the pial structure through the substance of the brain, its 
lymphatic prolongations, and its ventricular relations make plain many 
of the symptoms of meningitis and account for some of the serious 
sequels of the disease. 



INFLAMMATION OF THE DURA MATER— PACHYMENINGITIS. 

The dura mater, though a tough, resisting, fibrous structure, is subject 
to inflammatory invasion. As the outer or inner surface is affected, we 
speak of pachymeningitis externa and pachymeningitis interna. 

Pachymeningitis externa is not a clinical unit. When the outer 
surface of the dura becomes inflamed, it is always a secondary condition, 
the result of the extension to it of infection from adjoining structures. 
Fractures of the cranium attended by sepsis, osteitis, necrosis, and new 
growths in the cranial bones may be its starting-point. Suppuration 
of the middle ear sometimes propagates inflammation to the dural cov- 
ering of the temporal bone. A cranial gumma may incite it. Usually 
it is limited in extent. Very rarely considerable accumulations of 
purulent material between the dura and the skull may strip the mem- 
brane from the bone and occasion cerebral disturbance by localized 
pressure. 

When inflamed the dura becomes thickened and strong adhesions to 
the inner surface of the cranial bones are formed. The danger consists 
in a resulting sinus-thrombosis or in septicemia. The treatment is that 
of the surgical condition of which the pachymeningitis is the sequel. 

Pachymeningitis interna, pachymeningitis hemorrhagica, or hema- 
toma of the dura mater, is a chronic inflammation of the inner surface 
of the dura mater marked by one or more hemorrhagic membranous 
layers. 

Etiology. — The arterial changes resulting from alcoholism are fre- 
quently the cause of this condition. In undoubted instances the 
congestion following alcoholic abuse has determined the vascular 
rupture that furnishes the laminated membranes. In dements, and 
especially in paretic dements, it is a common post-mortem finding. In- 
fectious maladies, the exanthemata, erysipelas, and cachectic states, 
especially those marked by purpuric conditions, as scurvy, sometimes 
lead to it. It is more frequent among men than among women, and 
appears, as a rule, early or late in life. 

Pathological Anatomy. — Internal pachymeningitis is essentially 
characterized by the thickening of the dura and the deposition inter- 
nally of laminated new membranes of hemorrhagic origin. 1 Rasweden- 
kow 2 insists that the first change is proliferation of the epithelial layer 

1 Meyer, "Path. Keport, 111. Eastern Hosp. for Insane," 1896. 

2 " Ziegler's Beitrag.," Bd. xxvii. 



PACHYMENINGITIS. 



75 



followed by fibrinous exudation and the formation of thin- walled capil- 
laries and that the primary condition is a toxemia. Barratt 1 thinks that 
intravascular separation of fibrin is a constant initial feature followed by 
the other changes and finds such resulting membranes free from bacteria. 
These layers vary in number from two or three to as many as twenty, and 
in consistency from that of freshly extravasated blood to tough, well- 
organized, leathery membranes. They present, according to their age, 
the colors of blood under similar circumstances elsewhere. The new 
ones are bright red, the older ones yellow. They are only slightly adhe- 
rent to the dura and to one another by fibrous connections, and are quite 
vascular when of some age. Their blood-vessels are delicate, poorly 
developed, and readily degenerate, thus furnishing new hemorrhages, 
which separate the older layers or form new ones on the cerebral sur- 
face. Adhesions to the arachno- 
pia are practically wanting. The 
cerebral convolutions are flat- 
tened if the stratified new forma- 
tion attains considerable propor- 
tions, and the cranial bones may 
also present pressure atrophy. 
In children the ossification of 
sutures and fontanels is retarded. 
This form of dural disease is 
usually found at the vertex, in 
the distribution of the middle 
meningeal arteries over the motor 
zone, but occasionally the basal 
fossa? are involved. 

Symptoms. — The symptoms 
of the early stage before hemor- 
rhages have occurred, and when 

+1-.^ ,^~~^,-,,-, :„ i • n Fig. 26.— Pachymeningitis interna in a rachitic 

the process IS purely lnliamma- child with scurvy. The different layers, with cotton- 

forv fire x-pvx- Vflfrnp* Tn mnmr w ° o1 P Ied g etsint erposed, are seen on the right side of 

LUiy, die ver\ \ague. -LU manj the skull anteriorly (Southerland). 

cases no suspicion of the disease 

has been raised during life. The first recognizable symptoms attend 
the formation of a hematoma large enough to produce cerebral indica- 
tions. These consist of pain in the head, intellectual troubles, loss of 
memory, awkwardness in muscular movements, insomnia, vertigo, 
rarely vomiting, limited or Jacksonian convulsions, apoplectiform attacks, 
rigidities and monoplegias presenting remissions. The temperature is 
fickle and uninstructive. Daring the convulsive attacks it attains a 
high degree, but in the intervals may be subnormal, normal, or slightly 
elevated. 

Course. — As the early symptoms escape recognition, the duration 
of the disease is indeterminate. It usually runs a protracted course, 
and may in rare instances terminate in recovery, with resorption of most 
of the new tissue. As it is practically an expression of a serious or 
hopeless underlying condition, the ordinary end is death. This may 

1 "Brain," 1902. 




76 DISEASES OF THE CEREBRAL MENINGES. 

follow an apoplectiform seizure or a comatose condition, but usually is 
preceded at intervals by a number of such attacks, each of which leaves 
a certain trace behind it in the form of added mental or motor dis- 
ability. 

Diagnosis. — The diagnosis is difficult. In drunkards, dements, 
and cachectic children the appearance of the cerebral symptoms men- 
tioned should call the disease to mind. A history of preceding apoplec- 
tiform attacks, with practically complete remissions, would strengthen 
the suspicion. The thickened membranes form anatomically a subdural 
tumor, and at times present all the symptoms of a new growth in that 
locality. The nocturnal cephalalgia of syphilitic meningeal involvement 
and other luetic features will usually differentiate that disease. The 
distinction from tubercular meningitis in children rests upon the absence 
of constipation, abdominal retraction, severe headache, rigidity of the 
neck, and intense respiratory and circulatory troubles. In adults, cere- 
bral apoplexy usually is of more rapid onset, but cerebral thrombotic 
softening often presents a parallel symptom group. 

Treatment consists of measures to relieve the basic condition. Alco- 
holic addiction, infectious diseases, and the cachexia? having received 
appropriate attention, the various cerebral indications are met as they 
arise. Quiet, the ice-cap, elevation of the head, antispasmodics, cathar- 
tics, sinapisms, hot foot-baths, and other means to decongest the cerebral 
circulation will be of service during the convulsive attacks. Ergot 
should not be advised, as the bleeding vessels, devoid of muscular 
layers, would be placed at a still further disadvantage by the increased 
arterial tension. Monro and Ballard reported a number of cases in 
adult alcoholics successfully treated by trephining and the evacuation 
of the clots. When the diagnosis can be made, such procedure is ur- 
gently indicated. 

PIAL HEMORRHAGE. 

Pial hemorrhage, or meningeal hemorrhage, takes place either 
outside of the arachnopia, on the inner surface of the dura, or within 
the meshes of the pia, or in both locations at once. The extrapial 
variety of meningeal hemorrhage may be found at all ages, but is most 
common in the new-born. In about one-half of the cases still-born 
children present this accident, apparently due to protracted labor, some- 
times to instrumental delivery, and even to precipitate birth. In one- 
third of the cases of asphyxiated new-born, Cruveilhier claims that 
subdural hemorrhage is the main difficulty. The clots are commonly 
found over the convexity, and are, in surviving cases, a pregnant source 
of idiocy and cerebral palsy. 

Later in life pial hemorrhage is usually produced only by extreme 
violence to the skull, as in concussing injuries or fractures. The hem- 
orrhage may come from a dural sinus or from the meningeal arteries. 
It practically requires a fracture with displacement or a penetrating 
wound to cause sinus bleeding. The location of the middle meningeal 
artery in a bony channel at the anterior inferior angle of the parietal 



PIAL HEMORRHAGE. 77 

bone, a frequent seat of fractures and direct violence, renders it particu- 
larly liable to injury. In many cases the hemorrhage from the meningeal 
vessels takes place at the contre coup point. Certain debilitating and 
infectious conditions predispose to and may rarely cause subdural hem- 
orrhage ; for instance, hemophilia, purpura, small-pox, scarlatina, 
typhus, typhoid, and acute rheumatism. It is found in chronic alco- 
holism, especially after a debauch. A ruptured meningeal aneurysm 
may flood the subdural space. 

The onset is acute and marked by apoplectic seizure and rapidly 
developing unconsciousness. In traumatic cases the patient not seldom 
rallies more or less from the first bewilderment of the concussion, and 
after a variable interval of minutes, or even hours, sinks into uncon- 
sciousness. The cortical irritation is manifest in one-sided or more cir- 
cumscribed and repeated convulsions, rigidities, and tremors. The 
pupils dilate unevenly, the coma becomes profound, the pressure indi- 
cations intensified, and the patient usually dies in from twenty-four to 
seventy-two hours, unless relieved by operation. 

Intrapial hemorrhage takes place within the pial spaces, or strips the 
pia from the cerebral cortex. It is the usual meningeal hemorrhage of 
adult life, and its common location is toward or in the basal region. 

The extravasated blood may widely infiltrate the pial spaces or 
merely form diffuse ecchymotic discolorations. In large quantities it 
may force itself into the ventricles through the transverse fissure, and 
even travel down into the pial spaces of the cord. Usually it forms a 
thin covering over the surface of the convolutions, dipping into and fill- 
ing the intervening sulci. Under the hemorrhage the surface of the 
cortex often appears softened and lacerated. Ordinarily the blood is of 
arterial origin ; rarely it comes from veins and very exceptionally from 
a ruptured sinus. Except in traumatic cases, disease of the vessels, 
such as aneurysm, miliary aneurysm, sclerosis, atheroma, fatty degenera- 
tion, or acute infectious softening of their walls, furnishes the essential 
element of causation. It follows that periarteritis and endarteritis are 
the initial steps in the process that eventuates in hemorrhage. The de- 
velopment of these conditions is taken up more at length under the 
diseases of cerebral arteries in Part III, to which the reader is referred. 

The onset of this form of meningeal hemorrhage is also acute and 
apoplectic, with a rapid downward tendency toward death. There 
may be partial temporary restoration to consciousness, but the patient 
presents indications of great shock and feebleness. A recurrence of 
apoplectic symptoms is usually quickly followed by death. Previous in- 
dications of localized disease, such as aneurysm of the basilar or other 
large vessel of the base, may have been present in the form of cranial- 
nerve palsies with the usual features of endocranial tumors. The apo- 
plectic seizure is usually less sudden and violent than in cerebral hem- 
orrhage of the ordinary capsular variety, and often rather gradually 
develops the full apoplectic state and profound coma. Hemiplegia and 
conjugate deviation of the head and eyes have been noted in rare cases, 
but their absence is the rule, and aids in differentiating this condition 
from cerebral hemorrhage. Epileptiform and tetanic features are 



78 DISEASES OF THE CEREBRAL MENINGES. 

occasionally present and imply cortical irritation. The pulse may be 
slow and respiratory difficulty present. At first the rectal tempera- 
ture is reduced, but returns to the normal and rapidly mounts as death 
approaches. This takes place, as a rule, in from a few hours to a few 
days. Rare cases have endured a week, and still rarer ones survived. 

The diagnosis of intrapial hemorrhage is difficult. It closely resem- 
bles cerebral hemorrhage, cerebral thrombosis, and the hemorrhage arising 
from pachymeningitis interna. The chief symptoms on which reliance 
is to be placed are the rapidity of onset and the quickly increasing symp- 
toms without paralysis and convulsions. An internal pachymeningitis 
usually presents a significant history of headaches, and occurs in a lim- 
ited class of patients with gross degenerations. The differential features 
of cerebral hemorrhage and softening are tabulated in Part III. 

The outlook is extremely grave and death is almost certain to ter- 
minate the case. In these days of aseptic cranial surgery an exploratory 
opening is allowable, and furnishes practically the sole means of con- 
trolling the hemorrhage and saving the patient. 



CHAPTER II. 
INFLAMMATION OF THE PIA MATER, 

Leptomeningitis, acute cerebral meningitis, cerebrospinal meningitis, 
purulent meningitis, inflammation of the soft cerebral coverings, is an 
acute, sometimes epidemic disease of a heteroinfectious character, con- 
sisting of inflammation of the pia mater and marked by an irregular 
clinical course. 

A general description of leptomeningitis will be followed by an out- 
line of some of its more important clinical varieties. 

Etiology. — The pial structures can be invaded in but two ways : by 
traumatic or destructive lesions of the bony and fibrous envelopes of the 
brain on the one hand, or through the vascular supply on the other. To 
the first group belong those cases of meningitis arising from direct in- 
oculation, as in cranial fracture and septic extension from neighboring 
foci in the scalp, face, cranial bones, the middle ear, the mastoid cells, 
the nasal fossse, antra, and sinuses, and from the orbit and pharynx. 
To the second group belong the larger number, which, formerly called 
idiopathic, are now known to depend on microbic infection. The 
exact infection path is often problematical. Ortman pointed out the 
presence of coryza in a large proportion of the cases, and supposed that 
the infection reached the pial space through the lymph-channels of 
the nasal vault, which are continuous with those of the brain. 

In the epidemic form Scherer 1 again calls attention to the severe 
1 "Centralbl. f. Bakt. u. Parasitenkunde," April, 1895. 



INFLAMMATION OF THE PI A MATER. 79 

nasal catarrh at the commencement of the attack. Weigerts in eighteen 
cases found purulent nasal catarrh, and demonstrated Weichselbaum's 
Diplococcus intracellularis meningitidis in the secretions. In fifty per- 
sons not suffering from the disease he found this diplococcus in two in- 
stances and supposes that it is inhaled, taken up by the leukocytes, and 
by them carried into the lymph-spaces of the brain through the nasal 
vault. Further importance has been given to this pathway by the ex- 
aminations of Westenhoeffer. 1 Flexner and Barker 2 emphasized the 
probability of the infection atrium being in the intestinal tract, but 
more recently Flexner has subscribed to nasal invasion as the most 
common in the epidemic variety. This has been very fully sustained 
by others, and especially by Debre. 3 Flugge estimates that under 
epidemic conditions the number of carriers is ten to twenty times 
that of meningitic cases. Droplets from the respiratory tract are sup- 
posed to convey the infection. The close relation of pneumonia to 
meningitis has for a long time pointed to the lungs as an invasion route. 
As a clinical fact, any infection at any near or remote point may induce 
meningeal inflammation by way of the vascular system. 

Bacteriologically, a case of acute meningitis may present one or many 
organisms. Those most frequently found alone are Weichselbaum's 
diplococcus, Koch's bacillus, the pneumococcus, the streptococcus, the 
typhoid bacillus, 4 and the bacillus coli. In association with them, and 
perhaps often as a secondary infection, are found the staphylococcus 
aureus and albus and various indeterminate streptococci and bacilli. 
The most common of all and the most significant are the bacilli of 
tuberculosis, the pneumoeoccus, and the diplococcus intracellularis. 
These microorganisms are found in the meningeal fluid, but may, as in 
a general pneumococcic infection, be widely distributed throughout the 
body. Lately the diplococcus of Weichselbautn has been demonstrated 
in the pus of arthritis occurring in a case of meningitis, and also in 
the blood. 5 Osier, in the Cavendish lectures for 1899, made the follow- 
ing practical classification : 

, >> r 1. Of cerebrospinal f (a) Sporadic. \ Diplococcus intracellu- 

53 J fever. 1 (b) Epidemic. J laris. 

I \ 2. Pneucococeic. j "JSKKlfcSEL" '" " ^ } P™ 

1. Tuberculous Bacillus tuberculosis. 

{(a) Secondary to pneumonia, endocardi- 'j 
(^Secondary to disease or injury of \ Pneumococcus. 
cranium or its fossa. J 

C (a) Following local disease of cranium "1 1: ■ „„ e „ „ r .„ 

„ P7nwni(1 or a local infection elsewhere. I Yar ^J°- * a .♦- 

3. Pyogenic. 4 (ft) Terminal infection in various \ f^. occl and strep " 
l chronic maladies. J t0c0CC1 ' 

4. Miscellaneous J In J^ld fever influenza diphtheria, 1 **£*! ^dllus, influ- 
acuteinfections. g^^^-mom^ ^a bgilhi *£o- 

^. J COCCUSj glc. 

It will have been noticed that leptomeningitis is found in fre- 
quent association with the other infectious diseases. Curschmann has 
noted it in small-pox and scarlatina, both with and without purulent 

1 "Berlin, klin. Woch.," June 12, 1905. 2 "Am. Jour. Med. Sci.," Feb., 1894. 

3 "Recherches Epidemiologiques sur la Meningite," Paris, 1911. 

4 Daddi, "Lo Sperimentale," July, 1884. Ohlmacher, "Jour. Am. Med. Assoc," 
Aug. 28, 1897. 

5 Gynn, "Phila. Med. Jour.," vol. ii, No. 24. 



80 DISEASES OF THE CEREBRAL MENINGES. 

otitis. It is not rare after typhoid. It is common with pneumonia. 
All pyemias, whatever their source, have their recorded cases. Acute 
articular rheumatism is frequently attended by meningeal symptoms 
which are customarily attributed to rheumatic inflammation of the 
serous brain-envelope, but Ball, 1 in at least 3 out of 69 such cases, 
found a purulent effusion, and serous exudation was present in 35. 
Mumps are often associated with meningitis and epidemics of both have 
been concurrently noted. The same is true of coryza, which, like paro- 
titis, is sometimes undoubtedly due to the lancinate micrococcus. A 
most marked relationship exists between pneumonia, influenza, and men- 
ingitis. They may follow one another in a given patient. They are 
apparently interchangeable in a grippal epidemic, and present remark- 
able bacterial analogies. In pneumonia of the apex a meningitic 
disturbance sometimes arises that is not marked anatomically by any 
evidence of inflammation. Cultures in such cases have also been 
negative. 2 The clinical picture, however, is that of acute meningitis, 
and further investigation may yield positive findings. The so-called 
acute serous meningitis is generally secondary to some pyemic con- 
dition, and in some instances the clear meningeal fluid has contained 
streptococci. 3 Insolation is undoubtedly at times attended by a menin- 
geal congestion that may develop into active inflammation with a ten- 
dency to chronic changes. 

Pathological Anatomy. — The pathological changes in the meninges 
are more or less circumscribed when due to infection by extension, and 
are then often limited to the neighborhood of the primary lesion. On 
the other hand, infection by way of the circulation gives rise to a gen- 
eralized meningitis which may be most intense at the vertex or the 
basal region. The dura mater, except at the site of bone disease or 
similar infection center, is practically intact and is readily removed. 
The pia presents a roughened, marbleized appearance. The vessels 
are engorged with blood and the pial spaces are filled with a serous, 
milky, or purulent exudate, which follows the vascular courses, fills 
the sulci, and, if sufficiently abundant, unbrokenly covers the con- 
volutions. At other times the exudate appears in discrete patches, 
which are, for the most part, found at the basilar outlets of the cranial 
nerves and vessels. Extensions sometimes accompany the auditory 
nerve into the internal meatus or follow the optic nerve into the 
orbit. The seropurulent deposit is more or less fibrinous, and the 
serous exudate sometimes is filled with flaky masses, which escape with 
it when the skull is opened. Ordinarily the inflammation follows the 
choroid plexuses into the ventricles, which are oftentimes dilated by the 
increased turbid, flocculent, pial fluid. 

The cerebral cortex, in cases of short duration and in the so-called 
serous form, may show little more than the evidence of increased vascu- 
larity. In severe and protracted cases minute hemorrhages are com- 
mon, both in the pial spaces and the brain-substance. The perivascular 
sheaths are blocked with exudate, and the cortex is edematous, infil- 

1 " These de Paris," 1869. 

2 Berge, Claisse, "Traite de Medecine," vol. vi, p. 529, Paris, 1894. 

3 Nobecourt and Delestre, "Annalesde Med. et de Chir. Infantiles," April 15, 1900. 



INFLAMMATION OF THE PI A MATER. 81 

trated with pus, and adherent to the pia, which cannot be separated from 
it without stripping off the gyral substance. Thrombotic softening and 
abscess formation may be encountered. 

The cord is affected in about one-third of the cases. Its meningeal 
and deeper conditions are similar to those of the cerebrum. The pos- 
terior roots seem especially vulnerable, and present marked inflamma- 
tory and degenerative changes of their hyaline and axis-cylinder ele- 
ments. The exudate is usually thicker on the posterior surface of the 
cord, probably from the usual dorsal position of the patient. This may 
also account for the preponderance of changes in the posterior part of 
the cord. 

From the gross appearance it is evident in severe cases that men- 
ingitis is attended by a certain degree of cerebritis. The anatomy of 
the meninges explains this. The histological changes consist of cap- 
illary and vascular dilatation in the pia and an active diapedesis into 
the perivascular sheaths. These are dilated and crowded with leuko- 
cytes and purulent elements. The neurogliar cells and network of the 
cortex show some proliferation. The bacteriology has already been in- 
dicated. 

The body organs in the secondary varieties show the varying lesions 
of the primary disease, such as tuberculosis, typhoid, pneumonia, in- 
fectious endocarditis, or local septic processes. Splenic enlargement 
may alone mark the infectiousness of the disease. 

Symptoms. — The incubation period of meningitis is an indefinite 
one. In some epidemics it has appeared to be somewhat less than a 
week. In the fulminant cases the severest manifestations of the disease 
are present almost in a moment, and death may occur in twenty-four hours. 
Usually there is an invasion period of several days or weeks, attended 
by malaise, discomfort, slight feverishness, and headache. More pro- 
nounced disturbance then ensues, and we have a varying period of ex- 
citement, followed by one of depression, stupor, coma, and death. 

The prodromal headache becomes severe, continuous, and of all the 
symptoms is the most constant and significant. It is particularly vio- 
lent and unmanageable. The patient constantly complains of it, and 
when stupor or coma has supervened, by holding the head in the hands 
and by moans and facial expression, he still indicates its often overmas- 
tering presence. In children it gives rise to the sharp cephalic cry that 
punctuates their stuporous state at frequent intervals. Ordinarily it is 
referred to the occiput or vertex, but is often diffuse. 

Delirium is common in children and frequent in adults. A mental 
fogginess is often early noticeable. The patient, racked by the cephal- 
algia, seems irresponsive, unimpressionable, and is hazy in his replies. 
The delirium is of a low grade generally, but may be wild and frantic or 
suggestive of the busy delirium of alcoholism and typhoid. Vomiting 
of a projectile character is rarely absent in children, but is less common 
in adults. The stomach seems simply intolerant and rejects without 
nausea the unchanged ingesta. It may be an early symptom. At the 
same time the tongue may be quite clean; later it is often thickly furred 
and suggestive of typhoid. The bowels are usually constipated and the 
abdomen retracted. 



82 DISEASES OF THE CEREBRAL MENINGES. 

Convulsions in the early stages, particularly in children, often occur. 
They are general in character and of protracted duration. When the 
convexity is invaded, they may later present a limited distribution, one 
side of the body, the face, or a single extremity being alone involved. 

Almost invariably there is more or less muscular rigidity. In most 
cases this is marked at the neck by a tendency to retraction that is 







Fig. 27. — Attitude of patient with cerebrospinal meningitis. 

highly significant. At first the patient complains of a feeling of nuchal 
stiffness and soreness, and finds slight relief in resting the head on a 
chair-back or over a firm pillow. In the comatose condition the head 
is often strongly retracted and the occiput drawn well between the 
shoulders. When less marked, an attempt to passively bring the head 
forward will provoke distress and resistance. A similar rigidity rarely 
invades the muscles of the lower jaw, producing slight trismus. It may 
involve the extremities, and when the meningitis has attacked the spine 
the trunk is often held rigidly in a position of dorsal extension. Ker- 
nig and Bull 1 first described a peculiar rigidity in the lower limbs. If 
the patient is placed in a chair one is unable passively to extend the 
knees owing to the contracture, which disappears when the thigh is 
straightened on the trunk. 

Kemig's sign can be readily sought with the patient in the dorsal 
decubitus by raising the lower extremity to a vertical position with fully 
extended knee. The muscular retraction of the hamstring group, if 
present, prevents full elevation. The age of the patient must be con- 
sidered, as in the aged full extension in this posture is not to be ex- 
pected. Joint disease and deformities must also be excluded. Accord- 
ing to Herrick, Osier, and others this sign is practically constant in 
this disease. It appears early and is certainly valuable. Muscular 
weakness is usually present and may be more or less localized. 

The cranial nerves in most cases sooner or later show invasion and 
furnish valuable diagnostic symptoms. The olfactory nerves are seldom 
disturbed, but occasionally the patient complains of olfactory sensitive- 
ness. Photophobia is a common symptom. The optic nerve is irritated 
by extension of the inflammation down its sheath. After a few days 
haziness of the disc and enlarged vessels are often seen ophthalmoscop- 
ically. The disc may be markedly obscured. Retinal hemorrhages^ 
1 "Berlin, klin. Wochens.," 1894-1895. 



INFLAMMATION OF THE PI A MATER. 83 

papillitis, and subsequent atrophy and blindness are occasionally en- 
countered. Choroiditis, or panophthalmitis, is sometimes present and 
may cause great injury to the eye or result in complete blindness. The 
third nerve is almost always affected. "When marked strabismus does 
not demonstrate it at a glance, by having the patient turn the eyes in 
various directions a lack of conjugate action becomes apparent. Question- 
ing may develop the history of visual uncertainties — haziness or transient 
diplopia. The pupils also furnish important signs. Early in the at- 
tack there is a tendency to miosis, which later is replaced by pupillary 
dilatation. The reflex to light is lost or greatly reduced in amplitude 
or activity. The pupils may be perfectly immovable. They are often 
unequal. The facial nerve is exceptionally paretic, allowing the face to 
deviate to the opposite side. At the same time the auditory nerve is 
implicated through its association with the facial nerve within the bony 
walls of the internal meatus. The loss of hearing that sometimes fol- 
lows cerebral meningitis is due principally to an extension of the inflam- 
mation to the labyrinth, and only exceptionally to destruction of the 
auditory nerve-trunk. Irritation of the auditory apparatus is appar- 
ent in the early stages of the attack. All sudden or loud noises greatly 
distress the patient. Implication of the hypoglossus in rare cases causes 
deviation of the tongue. Probably all other cranial nerves are similarly 
affected. Doubtless the common respiratory and cardiac disturbances 
are, at least sometimes, attributable to injury of the pneumogastric. 

In addition to the hyperesthesia of the special senses much tenderness 
is customarily found over the spine and limbs. The back of the neck 
is especially sensitive, and firm pressure of the muscular masses is usually 
resented. The entire head is more or less sensitive to deep pressure, 
and pain is provoked by gentle percussion over the skull. The paretic 
and sensory disturbances may be unilateral or monoplegic in distribution. 
The location of the disease causes these variations. 

Cerebral meningitis presents no uniform temperature curve. It may 
be ushered in by a chill and an elevation of the body-heat to 104° or 
higher. It may show a very low, even a subnormal, temperature at 
first, and terminate with a high range. The evening rise may default. 
Fickleness is the rule and, in a way, diagnostic. 

The pulse shows variation in two directions. During the early stage 
of excitement it is likely to be full, active, and greatly accelerated. 
Not uncommonly, however, the physician is surprised to find a slug- 
gish pulse of 40 or 60 and the temperature mounting above 100°. 
This dissociation of pulse and temperature is usually manifest sooner or 
later in meningitis, and furnishes a sign of capital importance. Toward 
the fatal end the temperature bounds upward, attended by a pulse of 
great, almost uncountable, rapidity. 

Vasomotor signs are not lacking. Herpes labialis is as common as in 
pneumonia and as significant. If the finger-nail be drawn across the 
integument of the abdomen or elsewhere, it is followed slowly by a con- 
gested red streak that persists for many minutes. Trousseau laid much 
stress on the phenomenon, which he called the tache cerebrate, and it is of 
some significance. Taken alone it is of no importance, as it is common 
to many conditions. The application of mild irritants or gentle heat is 



84 



DISEASES OF THE CEREBRAL MENINGES. 



likely to be followed by vesiculation and sloughing. Urticaria is often 
present. A red macular eruption which gives to cerebral meningitis its 
sometime name of spotted fever is of infrequent occurrence. It appears 
mainly on the abdomen and trunk, and may be mistaken for the pete- 
chial marking of typhoid fever. It is more like roseola. 

Early in the attack the respiration may be quickened. Later, in the 
stupor and coma, it is often slow and irregular. The Cheyne-Stokes 
variety is often observed, and is of very serious though not absolutely 
of fatal import. Biot's deep-sighing type of respiration is common in 
adult cases and undulatory or wave-like respiration is observed. The 
ordinary relations of respiration to the temperature and pulse may be, 
and often are, disturbed. 

The urine shows the general febrile disturbance, and is scanty, high- 
colored, and heavy. Sometimes albumin and sugar are found in quan- 
tities varying from a trace to large amounts. They are significant of 
irritation of the medullary centers in the floor of the fourth ventricle. 

The tendon-reflexes may or may not be much modified. Sometimes they 
are exaggerated, more often decreased. It is not uncommon to find them 
diminishing as the depressed stage comes on. Their obliteration after 
the disease has lasted a week or ten days in protracted cases is often 
noticed. They may be more disturbed on one side than on the other. 
The toe-sign is frequently encountered. 





105 
















-,fi 








f 1 I If 


F / m A AT 


E ft v 


J i ?\ z5 


• ± L J t 


*1 Er7 ^ t 


103 3 i_3E| 3^ 


r^ xJh t vs 


£ 3 rj i- t-G 


r in x 


§ i 1_t r rv 


Jt jii 


1 . f \i , ■ ' t 


H 33^ „„s 


102 5 tz 4.3- P tr^ 


n fl ' § 


i $ td Jc 


R h , 


p ±33 3 


Efh ^ 


tof 4 H 


ill/ -ft-^ 105 


1: 


a \t [Jv ^ 


— fe — -i — 


H-ffi:- fe-r-^- 


100 ■*— r^-4 ^--^^_—J 


¥ V H \J X, 00 






y_ 




99° 


] 95 







Fig. 28.— Partial temperature- and pulse-curves in a case of meningitis of the convexity, showing 
dissociation. Temperature, upper line ; pulse, lower line. Record taken every four hours, commencing 
at midnight. 



Course. — No two cases present parallel conditions as to course, 
symptoms, or intensity. A fulminant case may end fatally in a day. 
Protracted cases extend over several weeks and some are clearly sub- 
acute. An average duration of about fifty days has been noted by Tooth, 



INFLAMMATION OF THE PI A MATER. 85 

Barlow and Lees, and others in the sporadic forms, some extending beyond 
one hundred days. In the epidemic cases, according to Mallory and Wright, 
the average duration is about eleven days, perhaps indicating a more viru- 
lent variety of the coccus. An ordinary non-epidemic case presents perhaps 
a week of malaise, a week of excitement, and a week of depression, which 
usually terminates in deepening coma and death by cardiac failure. At 
any time, even when the patient seems to be in extremis, the symptoms 
may clear away and convalescence follow. A remission of symptoms may 
give false hope, to be destroyed by the return of the serious features of the 
disease in all their intensity. When the basilar region is principally af- 
fected, the course of the disease is likely to be cut short by bulbar inva- 
sion. The convexity cases are of longer duration and the patient thus 
affected is sometimes gradually worn out by the pain, delirium, and fever. 

During the period of excitement of functions, vomiting, delirium, 
vertigo, high temperature, muscular rigidity, spasms, convulsions, inde- 
terminate headaches, and hyperesthesia are the prominent features. 
They are gradually replaced by increasing apathy, stupor, and coma, in 
which the patient lies inert. He may be nearly relaxed or lie with 
retracted head, marked squint, and rigid limbs, passing urine and feces 
under him, and responding to strong stimulation slightly or not at all. 
The rapid respiration of the first period is replaced by the slow or 
irregular breathing that indicates increased intracranial pressure or 
pneumogastric irritation. Finally, deglutition is impaired, respiration 
becomes stertorous, and the patient slowly sinks or may expire in a 
convulsion. 

Various epidemics have shown numerous features of similarity 
among the cases that have marked their progress. At first the fulmi- 
nant cases have been common. At the end those of less and less sever- 
ity are met with. 

Diagnosis in the very early stage is difficult. When the disease is 
fully developed, and in epidemic conditions, a mistake would be almost 
impossible. No one symptom is constant, and it is a disease of protean 
aspects. The symptoms vary as the base or convexity is involved. 
Meningitis of the convexity is marked by excessive delirium, high tem- 
perature, convulsions, localized spasm, dysesthesia, and monoplegias. 
The cranial nerves are not involved, and ocular symptoms are slight or 
entirely wanting. 

When the base is affected, the temperature often has a low range or 
is subnormal. Cranial palsies are common, retraction of the head is 
nearly always present, and the dissociation of pulse, temperature, and 
respiration is marked. Optic neuritis declares the basilar location or 
extension of the disease. As a rule, infection by the blood-channels 
results primarily in meningitis of the convexity. In rare instances the 
meningitis is confined to the ventricular area and the choroid append- 
ages, but no distinctive symptoms indicate this limitation. The diag- 
nostic value of the headache depends upon its duration, intensity, and 
particularly upon its persistence after delirium has appeared or coma 
has ensued. The tenderness of the head and the pain on pressure are 
of some value. Vomiting is only significant when of the projectile 
character, unattended by gastric disturbance and fermentative changes. 



86 DISEASES OF THE CEREBRAL MENINGES. 

The temperature lends aid when out of keeping with the pulse-rate and 
respiration rhythm. The tenderness in the limbs, the rigidity of the 
neck, the contractures at the knee in the sitting attitude, are highly 
suggestive. Apathy, drowsiness, and mental obscuration in themselves 
should suggest the disease. The grouping of several of these symp- 
toms would justify a tentative diagnosis, which the appearance of squint, 
convulsions, delirium, optic neuritis, Kernig's sign, or the vasomotor 
symptoms would confirm. Gowers states that in suspected cases the too 
free vesiculation of the skin under heat or irritation would lend support 
to the diagnosis of meningitis. Lumbar puncture will also assist. In 
practice it should always be done. It furnishes, through bacterial tests, 
knowledge of the exact infection, often establishes the diagnosis, and 
sometimes contributes to beneficial treatment. In the diplococcus variety 
it gives us exact indications and the opportunity for the use of Flexner's 
serum. In meningitis the spinal fluid is usually turbid and may even 
be puriform, though it may be quite clear even when the cerebral mem- 
branes are covered with a purulent exudate. In tubercular meningitis 
it is generally clear and inoculation experiments are often required 
to demonstrate the tubercle bacilli. The cellular content is always 
increased. 

Differentially, the diagnosis is often much complicated by the associa- 
tion of meningitis with other affections which may overshadow it. As 
it occurs in the course of pneumonia, typhoid fever, cranial injuries, 
septic invasion, and pyemias, the original disease process may entirely 
absorb the practitioner's attention. From typhoid, Hirt 1 says, it is 
sometimes indistinguishable, presenting a similar temperature curve, 
splenic enlargement, rose spots, and the typhoid stool. WidaPs re- 
action is a helpful but not absolute sign of typhoid. The presence of 
pseudomeningeal symptoms in pneumonia of the apices has been men- 
tioned, and in pneumonia generally meningitis can only be determined 
by basilar symptoms. Uremia should be excluded by a thorough 
urinalysis. An attack of delirium tremens may be easily mistaken for 
meningitis, with which it is not rarely complicated. Single or double 
acute otitis in children, marked by constant pain and vomiting, delirium, 
and deafness, is usually confounded with meningitis. If the facial 
nerve escape, the deafness would point to labyrinthian disease and serve 
to exclude meningitis. Hysteria is sometimes mistaken for meningitis. 
The emotional and mental features, the normal temperature, breathing, 
and pulse, and certainly the stigmata of hysteria should differentiate it. 
In children the onset of nearly every febrile disturbance has been con- 
founded with meningitis. Here reliance must be placed on the charac- 
teristic temperature curves, eruptions, and clinical antecedents. The 
character of the infection can usually be determined by spinal puncture 
and appropriate bacteriological tests. 

Prognosis. — In expressing an opinion as to the outcome of a given 
case, the physician has three positive statements to make. First, the 
result is absolutely uncertain until death occurs or convalescence is 
firmly established ; second, the probability of a fatal termination is 
always pronounced; third, some trace of the disease is likely to remain 
1 Hirt, "Diseases of the Nervous System," New York, 1893. 



INFLAMMATION OF THE PI A MATER. 87 

permanently. The disease is full of surprises. The writer has seen 
a patient in deepest coma for hours, with convergent squint of the 
most marked variety, retracted head and abdomen, convulsed limbs, 
Cheyne-Stokes respiration, large quantities of sugar in the urine, and a 
pulse of 32, entirely recover. Again, cases that seem trifling or on 
the high road to recovery suddenly become worse and die. Purulent 
cases are practically always fatal. If a purulent focus within the skull, 
nose, ear, or throat is found, it renders the outlook extremely grave. 
A meningitis following pneumonia is practically fatal, but Stoeltzner l 
reports a recovery where spinal puncture showed both pus and the 
pneumococcus. The cerebrospinal form runs a more favorable course, 
the mortality varying from about thirty to sixty per cent, in various 
epidemics. Partial recoveries, however, greatly outnumber cures. The 
extension of inflammation to the labyrinth produces deafness, which in 
young children may lead to deaf-mutism. Optic neuritis is followed by 
dimness of sight or complete blindness. Local meningeal thickenings 
and cerebritis portend monoplegias, epileptoid convulsions, and mental 
defect. Though the disease is not one of proved contagiousness, sepa- 
ration of the patient from the other members of the family may be 
insisted upon with propriety. The tubercular variety is almost inva- 
riably fatal. 

Treatment. — The first consideration in the management of a case 
is the removal, if possible, of the infection atrium. Cranial suppura- 
tion and injuries demand immediate surgical attention. Optic, nasal, 
pharyngeal, intestinal, and pelvic cavities should be rendered aseptic if 
their organs or contents fall under suspicion. Intestinal antisepsis is 
always in order. To this end free catharsis and the administration of 
antifermentatives are indicated as well as by the usual constipation. 
Minute doses of calomel, ^ of a grain, repeated every half hour or 
hour until active results are obtained, can be highly recommended 
for this purpose. In addition, the mercurial has a widely diffused mi- 
crobicidal value. 

From the first the patients should be kept in a cool, quiet, moder- 
ately darkened room, and all annoyances to which their hyperesthetic x 
senses make them especially responsive should be prevented. Extreme 
delirium will often require a sedative. In the presence of the cephal- 
algia bromids, chloral, Indian hemp, and other ordinary means will 
practically always fail. The coal-tar derivatives are equally valueless, 
and nothing but morphin will give relief. Its hypodermatic admin- 
istration is by all odds to be preferred except in infants. If high tem- 
perature be present, antipyretic drugs must be employed with great 
circumspection. They often have no effect, and their depressing action 
sometimes constitutes a real danger in a disease marked by symptoms 
of disturbed cardiac and respiratory innervation. Tepid to cool baths 
with cold affusions to the head, sponging, and the pack may be used to 
better advantage. Hot baths are decidedly valuable. They often allay 
the delirium, reduce the temperature, and clear up the clouded mind. 
The use of an ice-bag or ice-coil to the head frequently gives comfort to 
the patient and renders the head-pain bearable. Counterirritation along 
1 "Berlin, klin. Wochens.," April 19, 1897. 



88 DISEASES OF THE CEREBRAL MENINGES. 

the spine is a measure of doubtful utility, and always attended by the 
danger of setting up serious ulceration or actual sloughing. 

In the depressed period sedatives are no longer required, and stimu- 
lants, like strychnin and whisky, will often need to be sharply pushed 
to meet the failing action of the heart or lungs. When coma has 
appeared, it may often be broken and sometimes happily ended by the 
application of a fly-blister to the nape of the neck. It should be suffi- 
ciently large, — two by six inches for an adult, — and extend from one 
mastoid to the other. If this is not efficacious or the coma again develop, 
a drastic cathartic — one to five drops of croton oil in emulsion — may 
render similar service. By recurring in turn to the blister, cathartic, 
and baths, with cool affusions to the head, no doubt the progress of the 
disease may be often hindered. Unfortunately, it usually again takes up 
its course, but occasionally such measures seem to definitely check the 
malady and recovery slowly follows. Aufrecht 1 recommends full hot 
baths of about 100° F. for ten minutes. Their apparent effect some- 
times is to reduce temperature, diminish the headache, accelerate the 
pulse, and induce sleep. As many as eight a day have been given with 
excellent results by Woroschilsky. 2 

The use of large doses of iodids with the expectation of causing re- 
sorption of the effusion usually only results in distressing the patient's 
stomach, reducing his strength, and increasing the vomiting. Shaving 
the head is rarely called for, but a heavy mass of hair may usually be 
removed with advantage. Mercurial inunctions seem at times to lend 
help even in the absence of syphilitic taint. It is immaterial whether 
they be applied to the scalp or to the limbs, so far as the effect is con- 
cerned, but the non-hairy parts are more convenient and less irritable. 
Crede's colloid of silver ointment and iodoform ointment in large doses 
applied to the shaven head have advocates, and may be properly em- 
ployed. Good results have been claimed for subcutaneous injection of 
the bichlorid of mercury in doses of ^ of a grain several times a day 
in children. In cases showing the diplococcus of Weichselbaum, Flex- 
ner's serum should be employed by spinal puncture. Favorable results 
from its use seem to be directly proportional to its early administration. 
Every suspected case must, therefore, be subjected to spinal puncture 
and bacteriological examination as an initial proceeding. 

Important items in the treatment of meningitis are the nursing and 
nutrition of the patient. A careful, intelligent, preferably trained, 
nurse who will exclude visitors and members of the family and prevent 
disturbing sounds, bright lights, and all annoyances, is the salvation of 
some cases. Thus only can constant watchfulness of pulse, respiration, 
and temperature, which may show extreme and critical variations in an 
hour, be provided and emergencies met as they arise. Nourishment in 
small quantities can usually be administered frequently. If the cerebral 
vomiting persist, morphin is practically the only measure we can rely 
upon to check it. In the stuporous states rectal alimentation will be 
serviceable, or the nasal stomach-tube in skilled hands may be employed. 
If deglutition is difficult, one of these is imperatively demanded. Large 
1 "Therap. Monatshefte," Aug., 1894. 2 Ibid., Feb., 1895. 



INFLAMMATION OF THE PI A MATER. go, 

quantities of soups, custards, whey, junket, beef-juice, and eggs may be 
given with advantage from first to last. The bowels must be active. 

The question of trephining the cranium and draining the meninges 
and ventricles has received favorable consideration in those cases where 
deepening coma and failing circulation point to increasing intracranial 
pressure. The results thus obtained, however, are not encouraging. 

Quincke, in 1891, suggested that the intracranial pressure could be 
easily relieved by puncturing the dural sheath of the lumbar cord with 
a hollow needle. The procedure has since been widely adopted. Fur- 
bringer 1 used the lumbar puncture one hundred times in eighty-six 
cases. In many of his non-tubercular cases sugar was found in the 
spinal fluid, but only exceptionally in tubercular meningitis. The 
presence of pus or tubercle bacilli or other organisms in many in- 
stances completed the diagnosis. In several cases in children a 
sinking of the fontanel showed that the intracranial pressure was re- 
duced. A. Fraenkel 2 has noticed the optic papillitis diminish and 
improvement in other symptoms after the puncture. The writer has 
observed a pulse of 160 drop twenty beats in an adult upon the re- 
moval of two ounces of fluid. As a means of diagnosis it has a pre- 
cise value when positive findings are furnished, but therapeutically has 
not accomplished much. In principle it seems seductively correct, and 
in a disease of such fatal character may be employed in suitable cases 
with proper surroundings when pressure symptoms are marked. Koplik 3 
contends that the best indication of intracranial or intraventricular pres- 
sure is furnished by a hollow percussion note obtained over the squamous 
portion of the temporal bones. The operation is a simple one. It is 
best performed with the patient lying on the side, the back bent well for- 
ward, thereby opening the spaces between the lumbar spines. Under 
full asepsis a hollow needle of one and one-half millimeters is introduced 
from without inward, about an inch from the middle line, between the 
third and fourth lumbar spines. This level is below the cord. The fluid 
at first usually flows rapidly, but later drop by drop, and shows the influ- 
ence of respiratory pressure. The amount withdrawn has varied from a 
few drops to several ounces. The puncture may be repeated as required. 

One danger of lumbar puncture is pointed out by Jacoby,*who sug- 
gests that where the meningitic process is confined to the cerebrum 
draining by the lumbar puncture may carry the infection down the cord, 
and thereby extend the disease. He also shows conclusively that it is 
impossible from the lumbar extremity to force fluids of a therapeutic 
character into the arachnoid spaces above the cervical region, unless 
puncture is also made into the ventricular space of the brain, when the 
fluid passes very readily from one end to the other of the cerebrospinal 
meninges. He advocates such flushing of the cerebrospinal axis by 
means of both the lumbar puncture and a small trephine opening with 
drainage from the lateral ventricle. 

In recovered cases treatment is directed toward building up the 

general health. Inflammatory thickening and remaining effusion may 

perhaps be benefited by iodid of potassium and mild mercurial courses. 

1 "Berlin, klin. Wochens.," April 1, 1895. 2 Ibid. 

3 "Med. Record," Sept. 29, 1906. V'New York Medical Journal," 1895. 



90 DISEASES OF THE CEREBRAL MENINGES. 

Weakened or paralyzed extremities should receive careful electrical and 
massage treatment as soon as the active febrile stage subsides. All 
severe physical and mental fatigue should be avoided for a long period. 
Exposure to the sun and the use of stimulants will be found especially 
detrimental. 

VARIETIES OF LEPTOMENINGITIS. 

The Diplococcus Variety of Meningitis. — In the description of 
leptomeningitis which has preceded, the epidemic and sporadic features 
have been made prominent, and cases due to the diplococcus infection 
have been the basis of the descriptions. 

Etiology. — In this variety the etiology of the disease is clear and 
definite ; it invariably is due to the invasion of the diplococcus of Weich- 
selbaum, which is very commonly found in pure culture in the mem- 
branes and ventricles of the brain, or in the fluid obtained by spinal 
puncture. It is probable that the germ finds entry through the respira- 
tory spaces, either by way of the nose or the lungs. Its well-known 
endemic and epidemic character furnishes one of the most serious dis- 
eases under circumstances where many people are compelled to live in 
narrow quarters — as in barracks, on shipboard, in schools, etc., but 
where sanitary precautions can be maintained and disinfection practised 
it is apparently readily controllable. 

The symptomatology embraces features which have been dwelt 
upon in previous pages. The onset, usually insidious, with headache 
and malaise, sometimes is abrupt. 

The course of the disease varies from a few days or weeks to even 
a few months, and in various epidemics shows a similarity of features, 
the early cases being more severe than those that develop later, so that 
toward the end of the outbreak the severity of the disease seems to be 
attenuated and the prognosis improved. 

Diagnosis of this variety rests upon the recognition of the bacterial 
infection, and this is obtained usually by spinal puncture. While one 
may always suspect the diplococcus in epidemic conditions, the proof is 
easily obtained. 

The prognosis varies under different conditions of a given epidemic, 
and in different epidemics it also shows a considerable range of mortal- 
ity percentage. On the whole, the prospects are better than in any 
other variety of meningeal infection, from 30 to 50 per cent, of cases 
recovering. 

The treatment, while embracing the general features of nursing and 
care which have been already outlined, must be said to turn specifically 
upon the evacuation of a certain amount of spinal fluid and the injec- 
tion of a certain amount of Flexner's serum. The usual dose for an 
adult is 40 c.c. By spinal puncture a similar amount of spinal fluid is 
evacuated, and immediately the serum is introduced into the spinal canal. 
The same or a somewhat smaller dose is repeated in twenty-four or forty- 
eight hours, depending upon the progress of the case ; and again later on 
one or more doses may be used if required. The percentage of recov- 
eries under this administration, when early employed, is decidedly 



VARIETIES OF LEPTOMENINGITIS. 91 

greater than under any other method of management. The patient 
should be treated as an infectious case, measures of isolation maintained 
to guard those who might otherwise come in contact, and in most large 
cities it is required to report cases of this sort to the health officers. 

The tubercular variety of meningitis, basilar meningitis, acute 
hydrocephalus, is a local manifestation of the action of Koch's bacillus, 
usually most intense at the base of the brain, commonly attended by 
distention of the ventricles, almost invariably if not always secondary, 
and practically always fatal. 

Etiolog-y. — The pathological process in this form of meningitis is 
clear and definite. The bacillus of tuberculosis carried to the meninges 
of the brain by the vascular system finds in the pial fluid and the perivas- 
cular spaces a suitable pabulum and an excellent breeding ground. In the 
great majority of cases a primary focus of tubercular infection is found in 
other organs. The absolute exclusion of such original disease is practi- 
cally impossible in the few remaining cases where it is not readily discov- 
ered. It has been suggested that infection might reach the cranial contents 
by way of the nasal vault and cribriform openings. This can not be denied, 
but seems improbable and lacks confirmation. Though tubercular infec- 
tion of the soft brain-coverings may occur at any age, the years of life 
between two and ten show an overwhelming proportion thus affected. 
Before the age of six months and in advanced years it is practically 
unknown. It gradually diminishes after the age of ten and is infre- 
quent after thirty-five. The other etiological factors are those that are 
common to all tubercular processes. Heredity, both tubercular and 
neurotic, has a significance. Urban populations, conditions of crowd- 
ing, winter and spring (the seasons of exposure and poor ventilation), 
depressing influences, deprivation, and tubercular contamination are in- 
cluded in the list of predisposing and exciting causes. Traumatism 
may induce a tubercular meningitis perhaps by reducing the resistive 
factor in the tissues that stays the bacillary invasion. At any rate, it 
is a common observation that spinal and head injuries in themselves 
rather trifling, are followed by the disease in numerous instances. 

Pathological Anatomy. — Upon opening the skull and reflecting 
the dura, hardly any inflammatory action is, as a rule, to be seen. 
The arachnopia is sometimes a little lacking in luster along the course 
of the main cerebral arteries. At the base, however, the morbid picture 
is comparatively uniform and striking. At the arterial circle of Willis, 
extending along the basilar furrows, between the peduncles and the 
pons, covering the interpeduncular space, and especially marked in the 
Sylvian fissures, is a thick, almost gummy exudate, dotted with small 
masses of a dirty whitish color. These are tubercles in various stages of 
development or degeneration. They frequently dot the pia on the lateral 
aspects of the brain and sometimes reach to the vertex. They are 
always grouped near the blood-channels and vascular spaces, through 
which evidently the infecting organism reaches the meninges. 

The exudate, often of a clear, jelly-like consistence, is frequently 
turbid, grayish-yellow, and not rarely purulent or even greenish. It is 
found in greatest quantities at the base, but ascends with the cerebral 
vessels along the pial spaces, filling the sulci and interlobular grooves. 



92 DISEASES OF THE CEREBRAL MENINGES. 

It travels down the perivascular sheaths into the cortical substance, and 
invades the ventricles through the transverse fissure. The inflammation 
is here propagated to the ventricular ependymal lining, resulting in a 
great increase of fluid, with dilatation of the ventricles and a condition 
which early gave to this disease the distinctive name of acute hydro- 
cephalics. This feature is seldom wanting and may, by pressure, cause 
marked flattening of the convolutions. 

The granular tubercles, usually visible at a glance, sometimes require 
a little search. If the pia be stripped off and floated in a little clear 
water, the tubercles can be much more readily distinguished. They are 
grouped about the arterioles or disseminated along the larger vessels in 
patches and small masses, which may rarely unite to form a continuous 
covering for wide areas of the brain-surface. They present the variations 
which mark tubercles elsewhere, depending upon their age and develop- 
ment or disintegration. Microscopically, they are often found to occlude 
the perivascular spaces, giving rise at times to small softenings and 
hemorrhages, which occasionally attain sufficient proportions to explain 
the focal symptoms that may have been clinically manifest. These 
infarcts are usually found in the basal ganglia and the cerebral peduncles. 
The perivascular extension of the inflammation determines more or less 
cerebritis, and when the pia is removed it often decorticates the brain in 
consequence of the soft adhesions that have formed. Infrequently there 
are slight adhesions between the pia and dura. 

In a large proportion of cases of tubercular meningitis the spinal cord 
is also invaded. The meninges, meningeal vessels, and the cord itself 
present features analogous to those found within the cranium. The exu- 
date is most marked in the anterior and posterior grooves of the cord, 
and the meningeal changes are always greater on the dorsal surface. 

Tubercular meningitis presents varieties in which the pathological find- 
ings are most marked at the vertex. This is so rare that the disease 
was formerly known and described simply as basilar meningitis. Occa- 
sionally a circumscribed tubercle or a tubercular mass gives rise to 
symptoms of, and constitutes, an intracranial tumor.' Again, the men- 
ingeal involvement is only a part of disseminated miliary tuberculosis, 
appearing at once in the head, lungs, intestines, peritoneum, and abdo- 
minal parenchymatous organs. In these cases, while all the pial struc- 
tures are the seat of granular tubercles, they are most profuse along the 
vascular routes.V Ordinarily, they are not attended with much exuda- 
tion and brain symptoms may be quite lacking during life. 

Bacteriologically the tubercle bacillus of Koch is always found, and 
usually is present alone. Secondary mixed infections are extremely 
rare and purely adventitious. A case has been met in which the 
pneumococcus was also present. Primary tubercular processes in other 
organs, as in the serous sacs, the lungs, the intestines, the mesentery, the 
mediastinum, or the genito-urinary tract, are commonly found. A single 
caseous mediastinal gland has served as the starting-point for the me- 
ningeal infection. 

Symptoms.— The onset of tubercular meningitis is insidious and its 
course protracted. Cases, however, manifest wide variations. The typi- 
cal cases occur in childhood. Those occurring later in life are usually 



VARIETIES OF LEPTOMENINGITIS. 93 

preceded by well-marked tubercular disease to which the meningeal 
complication is added in a natural order. - In adults transient pecu- 
liarities of a mental character, such as hebetude, anorexia, child- 
ishness, and irritability, may be /prominent for weeks before distinct 
meningeal symptoms appear. J Children, on the other hand, fre- 
quently present an antecedent appearance of good health, the primary 
focus of disease having been so insignificant as to produce no notable 
symptoms. They become peevish, fretful, and out of sorts. Appetite 
and sleep are disturbed. After a week or two of prodromal malaise 
with perhaps a little headache, an occasional vomiting spell, and slight 
febrile disturbance, they are noticed to be apathetic, then distinctly 
drowsy, and later stuporous. If disturbed, they complain of head- 
ache or manifest discomfort and may vomit. The triad of symptoms — 
headache, vomiting, and constipation — following a more or less protracted 
period of malaise, which may rarely extend over months, marked by 
general physical deterioration and often by great loss of flesh, has serious 
significance. The stuporous repose is often pierced, but not broken, by 
a sharp cry of pain, the hydrocephalic cry, which in some cases is fre- 
quent and distressing. It is apparently due to the head-pain. There is 
retraction of the head with more or less rigidity of the neck, and the 
entire spine may be fixed. Slight opisthotonos is common. The thighs 
are flexed on the trunk, the legs on the thighs, the abdomen becomes more 
and more retracted, and finally presents the scaphoid or boat-shaped hol- 
lowing that is classical. The masticatory muscles sometimes are simi- 
larly stiffened, and the Kernig symptom of rigidity of the knee when the 
hip-joints are flexed is usually present. 

The tendon-reflexes, sometimes indistinct, are often increased at first 
and gradually diminish as the depression and stupor develop. The vom- 
iting continues at intervals and is of the cerebral type, unattended by 
evidence of gastric disturbance. The temperature, though fickle, usually 
shows an evening elevation. It is rarely extremely high until the fatal 
termination of the disease, when it attains 103° to 105° F., or even 
more, but from 101° to 102.5° is frequently seen. Occasionally it 
drops below the normal and may show considerable variation in the 
course of an hour. 

The respiration is not notably disturbed until stuporous or comatose 
conditions obtain, when it is irregular, sighing, slowed, and of the 
Cheyne-Stokes variety ; but Simon 1 asserts that from the first there is 
a lack of harmony in the respiratory movements of chest and diaphragm. 
The pulse then becomes much altered. It is slowed, often irregular, and 
just before death becomes uncountably frequent. It is in tubercular 
meningitis, especially that the dissociation of pulse, temperature, and 
respiration is found. Its diagnostic value is great. Thus, when the 
temperature exceeds 100°, the pulse may show a subnormal rate, and 
the respiration be slow or rapid. 

As the lesion is usually basilar, involvement of cranial nerves is the 
rule. Sight is often dimmed, and the ophthalmoscope demonstrates 
changes in the fundus-picture in a majority o cases. Simple hyper- 
emia, marked congestion, and papillitis may be expected. Of pathogno- 
1 "La France Med.," March 29, 1895. 



94 DISEASES OF THE CEREBRAL MENINGES. 

monic importance is the not infrequent presence of tubercles in the 
retinal or choroid tunics. Very early there is disturbance of the third 
nerve in the form of pupillary inactivity and a tendency to miosis, which 
later gives way to wide dilatation. Squires * describes a rhythmical di- 
latation and contraction of the pupils caused by extending and flexing 
the head. As the head is bent backward the pupils slowly dilate and 
again contract when the head is brought forward, the pupillary variation 
beiug proportionate to the amount of flexion and extension. Strabismic 
deviations of the eyes, or fixity of the globes, should be carefully sought 
for. In older patients diplopia is frequently noted. A strong convergent 
upward squint, drawing the pupils almost to the inner canthus and turn- 
ing the globes well up is usual in deep coma. The facial nerve is rather 
frequently affected with a corresponding paretic condition of the face. 
Deviation of the tongue, pharyngeal and laryngeal distress, mark the im- 
plication of the posterior members of the cranial group. A The mental state, 
aside from the stupor, is one of confusion, often marked by moderate de- 
lirium. When the patient is roused or is able to respond he resents all in- 
terference. I Rapid emaciation attends the progress of the disease. Sphinc- 
teric control is not often disturbed, except that in the comatose state the 
bladder and bowels act automatically, and their contents are uncon- 
sciously voided under the patient. Retention of urine, however, is 
sometimes noted and persistent ; obstinate constipation is the rule unless 
intestinal tuberculosis causes diarrheal discharges. 

Vasomotor disturbances are manifest in flushes and pallor, which 
frequently succeed each other rapidly or appear side by side on face 
and trunk in peculiar distribution. The tache cerebrale is present. The 
persistence and intensity of the streaks on the skin and the ease with 
which they are produced give some significance to a phenomenon ob- 
served in many unallied conditions. 

Convulsions sometimes open the sequence of acute manifestations, but 
more often appear later ; very rarely are they entirely absent. Due in large 
part to the irritation of the bulbar region, they are usually generalized 
and protracted. Convulsive twitchings, especially in the face and hands, 
indicate the extension of the irritation onto the lateral aspects of the 
brain. By localized disturbances in the motor cortex, spasm of a Jack- 
sonian variety may be induced. Similarly paresis is often found, which 
may be localized. In cases of protracted onset, some wavering in the 
gait, or even marked staggering and clumsiness, are of the same signifi- 
cance. 

After a variable, active period of a few days, a week, or even longer, 
a marked remission of the stupor, convulsions, vomiting, and other signs 
of active disease is usually noted. It is frequently followed by a period 
of vacillating improvement that only too often gives false hope and ill- 
founded security. After a number of oscillations, in some of which 
the patient may seem to touch the border-land of complete relief, the 
disease again takes up its course to a fatal termination. Such remis- 
sions may last from one month to a year, 2 and terminate without cause, 
or apparently as the result of a fall, shock or intercurrent slight illness. 

1 "N. Y. Med. Kec," March 26, 1904. 

2 L'Hote, "These de Lille," 1904. 



VARIETIES OF LEPTOMENINGITIS. 95 

All the symptoms of depression reappear, the coma intensifies, the 
pressure indications increase, the temperature runs up, stertor comes on, 
the pulse is inordinately accelerated, and death from respiratory or car- 
diac failure closes the scene, often attended by convulsions, due, per- 
haps, to the asphyxiated blood state. Occasionally a stuporous or even 
comatose condition, lasting days and weeks, may precede the fatal ter- 
mination. Spinal symptoms are common. The rigidity of the back 
and lower extremities, and great tenderness along the spine and over 
the skin, indicate spinal involvement ; but the overwhelming cerebral 
side of the disease usually obscures the less strongly marked features of 
cordal extension. 

Course. — A disease marked by such pronounced variations of 
intensity, and even of localization, necessarily presents a lack of uni- 
formity in its course and duration. Most frequently it is subacute. 
Rare cases reach a fatal termination in a week or ten days after the 
onset of marked symptoms. On the other hand, the prodromal stage 
may extend over weeks and months, with remissions of all symptoms at 
intervals. Again, the mid-period, marked by fluctuation, may protract 
the disease for days and weeks. Ordinarily, the malady presents four 
fairly marked clinical stages : (1) The prodromal period, of indefinite 
length ; (2) the period of irritation and excitement, varying from a few 
days to a week ; (3) the period of oscillation, lasting about as long, and, 
finally, (4) the period of marked depression, attended by paralytic 
features, deepening coma, and death. This refers principally to the 
disease as it occurs in childhood. Tooth noted an average duration of 
fourteen days in 29 cases, of which the shortest was of five and the longest 
thirty-three days; yet exceptional cases run through many months. In 
adults it is likely to run a more varied and protracted course, and in the 
rare senile cases it often provokes but insignificant disturbances. 

The diagnosis is avowedly difficult. In the prodromal period it is 
never positive. AVhen drowsiness, headache, vomiting, and constipa- 
tion are found following a week or more of malaise and petulance, the 
meningeal character of the trouble would be pertinently suggested. 
The detection of a primary tubercular process, or of tubercles in the 
retina, is a practical confirmation of the diagnosis. Strong hereditary 
tendency to tuberculosis, and more emphatically a family history of 
several cases of tubercular meningitis, would raise a strong presump- 
tion, when attended by the cerebral triad, headache, vomiting, and con- 
stipation, that tubercular meningeal infection had taken place. Con- 
tinued exposure to tubercular infection has some significance. The 
differential diagnosis from acute meningitis depends principally on the 
subacute onset and lower grade of intensity of all the symptoms in the 
tubercular variety. This is manifestly indefinite, and clinically the two 
forms of meningitis can not always be distinguished. Quincke's punc- 
ture furnishes a practical test. The bacillus tuberculosis is found in 
the spinal fluid in about four-fifths of the tubercular cases. Positive 
inoculation tests in guinea-pigs are equally valuable as proving the 
tubercular character of the meningitis, even when no bacilli can be 
found in the fluid by immediate microscopical search. In other cases 
the presence of the pneumococcus or of pus has made a differential diag- 



96 DISEASES OF THE CEREBRAL MENINGES. 

nosis possible. It is probable that observations of the opsonic index 
may be of some diagnostic importance here, as in pulmonary and other 
wide-spread tubercular processes. The positive tuberculin (von Pirquet) 
and ophthalmic tests have a value only as showing the presence of a 
tubercular process somewhere in the body. 

Prognosis. — Practically the only hopeful point in prognosis is the 
possibility of a mistaken diagnosis. A few undoubted cases of tuber- 
cular meningitis have recovered, and the post-tubercular lesion has been 
found after death from subsequent and unrelated causes. Dr. G. Fut- 
terer, 1 formerly assistant to Rindneisch, relates a case in which tuber- 
cular meningitis had been diagnosed by Prof. Leube. Five years later 
calcareous tubercles were found in the spinal meninges. Henoch, 
Pollitzer, Freyhan, and Avanzino 2 also report cases that have a similar 
bearing, and A. E. Martin 3 has been able to tabulate 20 undoubted 
cases recorded since 1894. Their extreme rarity hardly invalidates the 
rule of fatality. Owing, in some cases, to the difficulty of a differential 
diagnosis, the physician should always maintain a margin of reserve. 
This is particularly important in the oscillatory period of the disease, 
when apparent recovery may be most deceptive. 

Treatment. — The same general management and care should be 
employed as in acute meningitis. Actuated by the beneficial results of 
iodoform injections in tubercular joint-disease, in Germany inunctions 
of the shaven scalp with the same medicament have been warmly advo- 
cated. They may be tried. All are united on the use of calomel in 
small repeated doses. The mercurial not only is the best agent against 
the constipation, but may have some effect upon the inflammatory process 
within the skull. The extreme tendency to rapid emaciation suggests 
the most careful and persistent efforts to maintain the nutrition by every 
possible means. When the stomach is intolerant, rectal alimentation 
may be employed and cod-liver oil inunctions are useful. Digestion can 
sometimes be assisted by peptonizing and predigesting the food. Stim- 
ulation by whisky or a good wine is important in the later stages. 
During the period of excitement sedatives are required. In children 
the bromid of potassium is a useful remedy. It frequently controls 
the headache and reduces the convulsive tendency. The action 
of the potassium salt in producing arterial contraction is increased 
by the addition of chloral, which may be profitably combined with 
it. Applications of ice or the cold coil to the head seem at times to 
give some comfort and relief from pain. Antipyretics, aside from fre- 
quent gentle sponging, are rarely indicated and usually do no good. 
The hot bath often effectually controls the convulsions. Of late the value 
of drainage or mere exploration of the peritoneum in tubercular infec- 
tion of that cavity has turned attention to the possible value of a similar 
procedure in tubercular meningitis. Some of these cases have been 
drained and the ventricles tapped with alleged temporary improvement. 
Quincke's lumbar puncture, which certainly reduces intracranial pres- 
sure and removes the fluid, has, in the cases reported by Strahan, been 

1 "Chicago Medical Recorder," June, 1895. 

2 "Rif. Med.," Aug. 20, 1903. 

3 "Brain," 1909, p. 209. 



VARIETIES OF LEPTOMENINGITIS. 97 

followed by recovery once. As a fatal ending is the only reasonable 
expectation when the diagnosis has been confirmed by the lumbar 
puncture, the injection of iodoform emulsions or other solutions within 
the spinal and cranial dura may be attempted with propriety. Serum 
treatment to improve the opsonic condition may be properly employed. 
In protracted cases tuberculin may be used in very small amounts, 
as there is supposed to be danger of producing a severe meningeal reac- 
tion, but such has not been my observation. 

Serous Meningitis. — A number of cases were first reported by 
Hugenin, Oppenheim, Eichhorst, and others presenting merely a very 
much increased cerebrospinal fluid, with a clinical history of a low grade 
of meningitis. Later, Quincke, by his spinal puncture, was able to 
make the diagnosis of this variety of meningitis, which he believed to 
be analogous to a pleurisy, and denied that it was of bacterial origin. 
In some cases the fluid distends the ventricles especially, and such have 
been called meningitis interna serosa. In other cases the external men- 
ingeal spaces were more affected, and the cortical pia, giving rise to the 
term meningitis externa serosa. British authors have apparently de- 
scribed the same condition under the term chronic infantile meningitis. 

In the etiology of the condition, though Quincke saw only vaso- 
motor or angioneurotic activity, involving mainly the choroid plexus or 
the cortical pia, many cases have been recorded in which the serous 
accumulation was undoubtedly secondary to infections. Finkelstein and 
Pfaundler have reported the presence of bacteria in the cerebrospinal 
canal. A preceding pneumonia or typhoid is a common clinical obser- 
vation, and even tuberculosis. A serous meningitis may arise from an 
otitis media, and in nursing children follows in some instances a gastro- 
enteritis. In older children whooping-cough and measles, in adults 
trauma and alcoholism, have seemed to act as causative factors. The 
infective bacteria presented by such cases embrace pneumococcus, staphy- 
lococcus, streptococcus, bacterium coli, tubercle bacilli, 1 and typhoid 
bacillus. They seem to present but slight virulence, and are found in 
very small numbers in the exudate of the meninges or of the spinal 
fluid. 

The pathological anatomy of serous meningitis is marked by a 
flattening of the convolutions and great widening of the ventricles when 
the fluid is mainly accumulated in these cavities. The fluid is greatly 
increased in quantity and perfectly clear in appearance. The brain is 
edematous. The cortical pia generally presents evidence of slight in- 
flammation and a swollen edematous condition. This is particularly 
marked in those cases where the accumulation of the fluid is mainly ex- 
terior to the ventricles. The lymphocytes are relatively few in the 
cerebrospinal fluid, the albumin increased in quantity. 

The symptomatology is neither so severe nor so typical as in ordi- 
nary acute infective meningitis. In nursing children, where the disease 
generally is secondary to intestinal disorders, it frequently is overlooked, 
but it may present very severe and rapidly developing symptoms, with 
elevated temperature and convulsions, leading to coma, rigidity of the 
neck ; Kernig's sign, changes of the pupil, and death in a few days. In 
1 Homen, Baliut, "Neurolog. Centralblatt," No. 21, 1909, p. 1184. 



98 DISEASES OF THE CEREBRAL MENINGES. 

older children symptoms vaguely referable to tbe meninges are com- 
monly presented for a long period, with suggestions of brain pressure. 
Fever, disturbances of vision, modifications of consciousness, slow, and 
irregular pulse, Cheyne-Stokes breathing, generalized and localized con- 
vulsions are encountered. In many cases the condition has been mis- 
taken for brain tumor. Choked disc, headache, vertigo, vomiting, con- 
vulsions, and palsy of cranial nerves may all be presented and make 
the differential diagnosis very difficult. In some cases serous meningitis 
follows continuously upon congenital hydrocephalus. In others, through 
remissions and intermissions, the clinical history extends over years. 

The course of the disease is various. Serous meningitis occurring 
in nurslings is usually of fatal termination, but recovery is not to be 
entirely excluded. The disease may run weeks and months and even- 
tuate in a chronic hydrocephalus, or this may develop later on in life, 
and some cases show a predisposition to subsequent acute attacks at long 
intervals during life in consequence of excesses, trauma, infectious dis- 
eases, and similar disturbing elements. Some cases of chronic hydro- 
cephalus developing in adults are due to this condition. 

The diagnosis is principally to be made by lumbar puncture. A 
large quantity of fluid is easily obtained, making its exit under high 
pressure. It is perfectly clear, but rich in albumin. A centrifuged 
specimen shows but few lymphocytes, and few or no organisms are to be 
found. Sometimes only by animal inoculation can the bacteriology of 
the fluid be determined. Chlorosis, sinus thrombosis, and uremia, which 
all cause increase of fluid and increase in the pressure under which the 
fluid is to be obtained, may offer complications in the diagnosis, so that 
after all, the clinical history must be depended upon very largely in 
making the diagnosis. 

Prognosis includes the probability of spontaneous cure, favored by 
repeated lumbar puncture. This takes place in a manner quite similar 
to that presented by a pleurisy with effusion, or a hydrocele subjected 
to repeated puncture. Quincke insisted that cases presenting one-half 
of one per cent, of albumin or less furnish a good prognosis. 

The treatment is already indicated. In making the spinal punc- 
tures it is important to withdraw the fluid very slowly, in order that 
the intracephalic pressure be not too rapidly reduced. As much as 100 
c.c. is sometimes withdrawn with benefit, and a repetition of the spinal 
puncture is indicated by a recurrence of the pressure symptoms. Even 
puncture of the ventricle has been used with advantage and success. In 
the more acute cases the ordinary treatment of meningitis is indicated. 

Chronic Leptomeningitis. — Leptomeningitis, as already men- 
tioned, is occasionally subacute. This form may become chronic. As 
the result of alcoholic excesses, syphilis, and insolation, sometimes a low 
grade of chronic leptomeningitis is developed. Post-mortem examina- 
tion frequently reveals such a condition which may have been unsus- 
pected during life. Among the chronic insane it is a very common 
finding after death. Clinically, except in the syphilitic form, its mani- 
festations are very uncertain and obscure. Stiffness of the neck and 
persistent slight headache, both marked by exacerbations, with some 



DISEASES OF THE FIRST AND SECOND CRANIAL NERVES. 99 

tenderness over the skull, may be complained of. Undue optic and 
auditory sensitiveness usually accompany the more severe periods of 
headache. All causes of cerebral congestion, such as stooping and 
muscular or mental exertion, cause distress and intensify the headache. 

The alcoholic cases are the least well marked. A low grade of optic 
neuritis may be present, and usually disappears if the alcohol is with- 
drawn. Slight mental cloudiness or delirium, due to the specific action 
of the poison on the brain-tissue, is frequently observed. Multiple 
neuritis and other indications of alcoholism are usually present, and 
often quite overshadow the meningeal symptoms. 

The syphilitic inflammation is usually circumscribed, and gives rise 
to local symptoms. It will be fully considered under the head of 
Syphilis of the Nervous System, Part VI. 



CHAPTER III 

DISEASES OF THE FIRST AND SECOND CRANIAL 

NERVES. 

Diseases of cranial nerves are broadly divided into those which affect 
the cortical centers, those which involve the nuclei, and those which 
involve trunks and peripheral portions. The peripheral nerves extend 
from the nuclei to the ultimate distribution of their fibers. A part of 
their course lies within the mass of the brain itself. While the peripheral 
portion of a cranial nerve may suffer independently of its nucleus, injury 
to the nuclear center is always followed by degeneration in the periph- 
eral part. It is not unusual for a peripheral nerve to be singly injured 
by traumatism, or even by disease, but, owing to the close anatomical and 
physiological relations of the cranial nuclei, the medullary centers are 
rarely individually diseased. Very often nuclear disease of the cranial 
nerves is but a portion of a more general nervous malady. The suc- 
cessive nuclear centers in the medulla, along the floor of the fourth 
ventricle, under the aqueduct of Sylvius, and on the posterior wall of the 
third ventricle, constitute the upward prolongation of the spinal gray 
matter. They may be involved with the spinal centers at the same 
period or at varying stages of a given general malady. The peripheral 
parts of the cranial nerves also participate in the general diseases which 
affect the spinal nerves and react similarly to infections and poisons. 
The analogy of the last ten cranial pairs to the spinal nerves should be 
clearly apprehended. The olfactory and optic nerves react more, as 
does the brain proper. They are, in fact, portions or lobes of the brain. 
To a less degree the same is true of the auditory nerve. 



100 DISEASES OF THE CRANIAL NERVES. 

Diseases of the Olfactory Nerve. — The exact cortical origin of 
the olfactory nerve is not known. Its pathway in the brain is not 
clearly traced. Its disturbance, usually considered of slight importance, 
is often overlooked. Ordinarily, the olfactory cortical center is assigned 
to the uncinate gyrus, or near by, in the cornu ammonis'in the floor of 
the lateral ventricle. 1 Certain cases of epilepsy in which an aura 
referable to the sense of smell was noted have presented post-mortem 
evidences of disease of the temporosphenoidal lobe near to or involving 
the uncinate convolution. The same is true of some cases of mental 
disease marked by hallucination of smell. It seems probable that the 
olfactory nerve is represented on both sides of the brain. 

A loss of smell on the side opposite to a lesion in the posterior por- 
tion of the internal capsule has been noted by Fere 2 and confirmed by 
others. Usually, however, the lesion is on the same side of the brain, 
and involves the olfactory tract, the bulb, or the nervous filaments, 
which are distributed to the nasal vault through the cribriform plate of 
the ethmoid. Disease of the middle cerebral artery near its origin from 
the circle of Willis may cause loss of smell in the corresponding nos- 
tril. This is probably through injury to the brachia of the olfactory 
tract. Basilar fracture often destroys the nerve at the cribriform plate. 
In such cases the loss of smell is an important localizing fact. Local- 
ized meningitis, caries of bone, tumors, or abscesses may have the same 
effect. Hydrocephalus may seriously compress these nerves. It has 
been claimed that tumors situated in distant parts of the brain provoke 
neuritis in the olfactory tract similar to the optic neuritis usually asso- 
ciated with encephalic neoplasms. In old age the olfactory bulb atrophies 
and the sense of smell diminishes. In hysteria smell may be entirely abol- 
ished. This may be a bilateral condition and exist practically alone, 
but is usually unilateral and confined to the hemianesthetic side of the 
body. Gowers mentions some cases in which the recognition of certain 
odors alone was lost. Overstimulation of the sense of smell will para- 
lyze it, and the loss may be permanent. Ordinarily, a strong stimulation 
for three or four minutes so blunts the sense that it no longer recognizes 
the particular odor, but recovers itself in about a minute. Continued 
exposure to strong odors usually result in permanently diminishing this 
special sense. Oversensitiveness is occasionally noted in neurotics, and 
can be cultivated. The blind and those who taste tea or inspect certain 
articles of commerce gain great sensitiveness in this way. Finally, the 
olfactory bulb may be congenitally wanting. 

The prognosis in loss of smell from disease of the olfactory nerve is 
usually bad. It depends on the cause in a given case. Catarrhal nasal 
conditions, fifth-nerve disturbance, and hysteria must be ruled out. The 
use of faradism is said to have done good in a few cases. It is applied 
to the mucous expanse over the turbinates, and is very painful. Snuffs 
containing strychnin or quinin may be tried. Oversensitiveness is con- 
trolled by morphin or cocain, but their use is attended by the danger 
of setting up an incorrigible habit. 

1 Zuekerkandl, ' ' Ueber das Riechsceiitrum. " 2 "Arch, de Neurologic " 1885. 



DISEASES OF THE FIRST AND SECOND CRANIAL NERVES. 101 

Diseases of the Optic Nerve. — The Visual Tract. — Only the 
infinitely short fibers between the layer of rods and cones and the retinal 
nerve-cells can properly be called peripheral optic nerves. The retro- 
ocular bundles that are named optic nerves by anatomists react to 
injury, as do other cerebral connecting tracts. Like them, if divided 
they never unite, while peripheral nerves unite readily under proper 
conditions. 

The term optic nerve, with this understanding, will, however, be 
used as ordinarily accepted. The retina is made up of two lateral 
halves supplied from corresponding sides of the brain, — that is to say, 
the right half of each retina is in anatomical connection with the 
right cerebral hemisphere and the left half of each retina with the left 
hemisphere. At the macula lutea, or point of greatest visual activity, 
these halves overlap. This central part of the retina is thereby abun- 
dantly supplied from both hemispheres. As the bridge of the nose cuts 
off much light that would enter the pupil from that direction, the temporal 
or outer halves of the retinae are rendered in part functionally inactive 
and their afferent fibers are less in number. The optic nerve in conse- 
quence contains many more fibers for the inner than for the outer halves 
of the eye-grounds. 

At the chiasm in man a partial decussation takes place. The larger 
number of fibers, those in relation with the inner or nasal halves of the 
retinae, cross to the opposite side. Those from the*temporal halves of 
the retinae pass backward on the same side. At this point a number of 
fibers enter the gray matter in the floor of the third ventricle. Back 
of the chiasm the temporal fibers of the right eye are accompanied by 
the nasal fibers of the left eye, and they together make up the right optic 
tract. In other words, the right optic tract contains all the fibers going 
to the right halves of both eyeballs. It is, then, clear that while division 
of an optic nerve causes absolute blindness of one eye, division of one 
optic tract would produce half-blindness of the corresponding sides of 
both retinae. This would manifest itself in blindness in the opposite 
halves of the visual fields, hemianopsia, owing to the fact that oblique 
rays of light entering the pupil impinge on the opposed portion of the 
retina. A glance at figure 29 will make this clear. Owing to the 
fact that the macula has a double supply the hemianopsic field always 
shows an indenture at the fixing point. In such cases direct vision 
may not be impaired in acuity, so thoroughly is each macula supplied 
by both hemispheres. The dividing line between the half-fields in a 
hemianopsic eye is practically vertical, but may incline one way or the 
other to a slight extent in various individuals. 

Injury dividing the chiasm longitudinally would cut off all the fibers 
to both nasal halves of the retinae and produce double temporal hemi- 
anopsia, marked by blindness for all objects to the right for the right 
eye and all objects to the left for the left eye. Enlargement of the 
pituitary gland or pressure through the floor of the third ventricle may 
cause this result. 

In extremelv rare instances a bilateral blindness in the nasal fields 



102 



DISEASES OF THE CRANIAL NERVES. 



is caused by symmetrical lesions in the optic nerves. This condition 
has been usually attributed to bilateral lesion of the outer portions of 




Fig. 29. — Diagram of visual paths (after Starr). 

the chiasm, but at this point the crossed and direct fibers are inter- 
mingled (see Fig. 29 A), and Shoemaker 1 insists that the process is due 
to neuritis invading the optic nerves symmetrically by way of the 




+ + Crossed fibers. 
3 3 Uncrossed fibers. 
'/.J* Uncrossed fibers of papillo-macular bundle. 

Fig. 29 A.— Diagram of the optic chiasm, from Wilbrand and Sanger (after Henschen). 

fibrous septa. These are quite uniform anatomical structures, as shown 
by Wilbrand and Sanger. 

The optic tract passing backward encircles the crus cerebri and 
enters the geniculate bodies, the anterior corpus quadrigeminuin, and 
1 "K Y. Med. Jour.," Feb. 4, 1905. 



DISEASES OF THE FIRST AND SECOND CRANIAL NERVES. 103 

the optic thalamus of the same side. From these ganglionic bodies 
fibers then pass outward and backward around the posterior horn of 
the lateral ventricle, to end in the cortex of the cuneus, the postero- 
internal portion of the occipital lobe. This portion of the occipital lobe 
represents, therefore, half-vision for each eye and is in relation with the 




Left. 



Right. 



Fig. 30. — Blindness in both temporal fields in a case of acromegalia due to injury of the chiasm by 
pituitary enlargement. The nasal fields are also contracted. 

lateral halves of the retinae on the same side of each eyeball. Any 
lesion that interrupts the visual pathway back of the chiasm, or destroys 
the visual centers in the cuneus, produces lateral homonymous hemi- 
anopsia. 




Left. 



Right. 



Fig. 31. 



-Homonymous lateral hemianopsia from an injury to the right occipital apex, 
lateral fields also contracted. 



The right 



The cortical half- vision centers of the cuneus are in turn brought by 
connecting fibers into relation with higher centers for visual memories, 
probably situated in and about the angular gyri of the parietal lobes. 
In these higher visual centers both eyes are represented in each hemi- 



101 



DISEASES OF THE CRANIAL NERVES. 



sphere. The parietal centers probably freely communicate through the 
eallosal crossway. Injury to the left parietal region in right-handed 
persons produces loss of visual word-memories, or icord-blindness, but 
does not necessarily cause hemianopsia. 

The fibers which supply the macula lutea of the retina occupy at the 
apex of the orbit the central portion of the optic nerve in close proxim- 
ity to the central artery and vein. They then become superficial on the 
outer side of the nerve and proceed in this position to the back of the 
eye. Aneurysm of the central artery or axillary inflammation of the 
nerve about the artery may so involve them that blindness of the center 
of the field develops. This condition of central blindness, or central 




Left. 



Eight, 



Fig. 32. — Scotomata in toxic amblyopia, consisting of increased size of blind spots, 

by the darker shading. 



hich are represented 



scotoma, is also common in tobacco and alcoholic amblyopia. The poison 
seems to have the greatest effect on the most used and consequently most 
sensitive fibers or their related parts. 

The loss of vision is sometimes limited to a quadrant of the field. 
The quadrant in the field is bounded practically by lines horizontal and 
vertical to the fixing point, which itself is spared. A case originally 
presenting hemianopsia may eventually recover in part and a quadrantic 
loss alone remain. It is probable that these quadrants are specially 
represented in the occipital cortex. In organic hemianopsia usually the 
seeing half of the field is also more or less peripherally reduced. The 
blind portion of the field may not be uniformly affected, some fractional 
vision remaining at various points. Rarely cases have been noted in 
which there was hemianopsia for certain colors alone. In tobacco blind- 
ness the central scotoma, as a rule, varies for different colors. 

In locating the lesion that causes hemianopsia, the he mianopsic pupillary 
reaction of Wernicke is of value. If the pupil responds when a narrow 
beam of light falls on the blind retina, the lesion is back of the genicu- 
late bodies. The presence of this reaction indicates that the pupillary 
nerves are not involved. They accompany the optic tract as far as the 
geniculate bodies. The test must be made with great care. The reac- 



DISEASES OF THE FIRST AND SECOND CRANIAL NERVES. 105 

tion lias a positive significance when present, that its absence lacks. 
A double temporal blindness by itself is positive evidence of disease of 
the chiasm. When an optic tract is involved, the cms is almost invari- 
ably affected at the same time by the same lesion, so that paralytic 
body-symptoms on the same side as the blind field or opposite to the 
blind retinal half are present. Other cranial-nerve lesions are likely 
also to be present. Lesions of the geniculate bodies, the corpora quadri- 
gemina, and the optic thalami almost invariably involve the internal cap- 
sule and produce paralysis in the body on the opposite side. A pure bilat- 
eral homonymous hemianopsia may be produced by injury to the cuneus. 




Left. Right. 

Fig. 33.— Quadrantic loss of visual fields following meningitis. Some peripheral contraction also present 

in the right field. 

A transient hemianopsia occasionally is a symptom of migraine and 
lithemia. It is not impossible that hysteria may produce it. but concen- 
tric contraction of the field and changes in the color formula are usual 
in hysteria. In organic hemianopsia the reductions of the field embrace 
form and colors equally. 

The optic nerve is often injured by intra-orbital disease, such as tumor 
or aneurysm. It may be cut oil' at the foramen opticum by a basilar 
fracture, or involved by inflammation from caries of the sphenoid. An 
extension of inflammation down the -heath in meningitis is not rare. 

The chiasm is injured most frequently by pituitary tumors, by syph- 
ilitic growths, and by pressure from the third ventricle in hydrocephalus. 
Gouty changes and interstitial hemorrhage have also been observed. 
Diseased carotids may press upon it. 

The optic tract may be involved in basilar tumors or those on the in- 
ternal aspect of the temporosphenoidal lobes.- A patch of thickening 
in multiple sclerosis may atfect it. The intracerebral path of the 
visual tract is often affected by tumors, hemorrhage, softening, and 
traumatism. 

The Papilla and Retina. — Associated with or consequent upon 
many organic processes in the brain and spinal cord, the optic-nerve head 
and the retina are diseased. In two-thirds or more of the cases of en- 
cephalic tumors papillitis, usually double, is present at some period. It 



106 DISEASES OF THE CRANIAL NERVES. 

presents ophthalinoscopically the choked disc. The onset, often sudden, 
may be insidious, and in some measure the rate of development is related 
to the activity of the new growth. While a long-standing growth in the 
brain may give rise to a sudden papillitis, a chronic process in the nerve- 
head is never associated with acute brain disease, except as a terminal 
condition or an accidental companion. Of much importance is the fact 
that a well-marked choked disc may not be attended by much loss of 
vision and no symptoms may call the patient's attention to its presence. 
In some cases temporary loss of vision, lasting from a few minutes to 
several hours, has been noted. Intense optic neuritis finally affects 
vision in all its modes. Acuity is diminished, the field is reduced for 
form and color, scotomata for both are frequent, and blindness may be 
induced. In most cases at some period the color fields will show vari- 
ations and interweaving somewhat similar to those of hysteria. The 
papilla is swollen and infiltrated with a plastic material that obscures 
the outline and enlarges and elevates the disc. The organization of the 
infiltrate and consequent shrinking causes the final damage to the 
entering nerve-fibers. Papillitis may terminate in recovery, but its 
legitimate end is more or less atrophy of the optic nerve, with im- 
pairment of vision or complete blindness. In many cases of brain- 
tumor with optic neuritis the papillitis subsides on the removal of the 
tumor. Even opening the skull widely may cause a reduction of the 
papillitis in inoperable brain tumors and prevent blindness. In other 
instances improvement in the brain-lesion is attended by decreasing 
papillitis. The intensity of the papillitis, therefore, has some diagnostic 
and prognostic value. 

Papillitis rarely results from brain-abscess, but in basilar meningitis a 
papillo- or neuroretinitis is extremely frequent. In this form the choking 
of the disc is less marked. Orbital disease is the usual cause of unilateral 
papillitis, but in rare cases a one-sided optic neuritis has been caused by 
tumor, generally on the same side of the brain. Wilder 1 notes that in 
ten cases where optic neuritis was distinctly greater in one eye than in the 
other, the tumor was on the side of the brain corresponding to the more 
intense inflammation. Marcus Gunn 2 found that the tumor and unilat- 
eral papillitis were located on the same side of the head in eighteen of 
twenty-four cases, and with greater uniformity in the tumors that were 
situated anteriorly. The localizing value of bilateral papillitis is prac- 
tically negative, as it is common to tumors in all parts of the brain, but 
is particularly frequent with cerebellar growths and those situated in the 
brain-axis. 

Optic neuritis also occurs in toxemic conditions. It is sometimes 
found in severe anemia, often in albuminuria and in lead-poisoning, and 
after infectious fevers. In the albuminuric form the retinal expanse 
is commonly invaded, but sometimes the changes are practically con- 
fined to the disc. 

Regarding the causation of papillitis, many theories have been 
adduced and rejected. In some cases it is clearly due to irritation 
descending the sheath of the optic nerve from intracranial inflamma- 
tion. The idea that it is due to intracranial pressure or pressure within 

1 "Chicago Medical Recorder," June, 1894. 2 "London Lancet," July, 1897. 



DISEASES OF THE FIRST AND SECOND CRANIAL NERVES. 



101 



the optic-nerve sheath in all cases has not been abandoned. Bordley 
and Cushing 1 contend that pressure producing distention of the optic 
nerve-sheath by cerebrospinal fluid is the sole cause, and support this 
contention with numerous clinical observations and animal experiments. 
In toxic cases it may represent the local action of the poison. Deutsch- 
mann 2 insists that it is due to pathogenic organisms which enter from 
without. Pressure is probably by far the most frequent cause, and the 
detection of a choked disc should always suggest abnormal intracranial 
pressure and the possibility of brain tumor. 

Atrophy of the optic nerve may (1) follow papillitis and retinitis 
or choroiditis; (2) it may result from injury or inflammation to the 
nerve-trunk; (3) it may be associated with sclerotic disease in the brain 
and spinal cord; (4) it may be due to diabetes, malaria, or syphilis; 
and (5) it may be of unknown causation. 

The atrophy consecutive to papillitis is easily understood, and of the 
same nature are the retinitic and choroiditic forms. Injury to the optic 
nerve naturally results in atrophic degeneration of the nerve-head. That 
form of optic atrophy found in about a tenth of the cases of locomotor 
ataxia, often present in paretic dementia, and not infrequent in multiple 




Fig. 34.— Optic neuritis. 



Fig. 35. — Atrophy of the optic nerve. 



or disseminated sclerosis, has an importance quite its own. Atrophy is 
found in amaurotic idiocy and in the cerebellar form of family ataxia. 

The symptoms and ophthalmoscopic pictures are tolerably uniform 
for the various forms. In the variety associated with tabes the disc is 
often grayish, translucent, and shows the stipling of the lamina cribrosa. 
In the postpapillitic form the translucency and stipling are less marked. 
In amaurotic idiocy there is a peculiar bluish spot at the site of the 
macula about twice the size of the disc, presenting in its center a 
brownish-red spot strongly contrasting with its surrounding patch and 
resembling a central embolism or hemorrhage. At the same time the disc 
1 "Jour. A. M. A.," Jan. 30, 1909. 2 "Ueber Neuritis Optica," 1887. 



108 DISEASES OF THE CRANIAL NERVES. 

is atrophic. In all forms of atrophy the disc is sharply outlined from 
the surrounding retina by its pallor and the vessels are diminished in size. 

Functional and Toxic Blindness. — The peculiarities of hysterical 
blindness will be detailed in the description of that disease. In such cases 
the loss of vision may come on slowly or suddenly. It is usually uni- 
lateral, and most marked on the paralytic or anesthetic side of the body, 
but the opposite eye is nearly always somewhat affected. The charac- 
teristics are contracted fields and inversion of the color formula. When 
apparently absolute, by using prisms or other suitable means, it can be 
demonstrated that the eye operates properly, but that ocular impressions 
are ordinarily neglected by the higher visual centers, where the disturb- 
ance must be located. In a very few such cases it is bilateral and com- 
plete, sometimes with dilated inactive pupils, in others with normally 
acting pupils. 

Disease in branches of the fifth nerve is sometimes attended by 
partial blindness. This is marked by considerable concentric contrac- 
tion of the field and some loss of acuity of vision. It is principally 
associated with disturbance in the dental branches, particularly those to 
the molar teeth. 

Acute anemia, the result of excessive hemorrhage, sometimes induces 
blindness that may be complete and permanent. 

A number of general toxic states, such as uremia and syphilis, and 
those clue to quinin and lead, may cause amblyopia. Uremic blindness 
is often of sudden onset, but may be preceded by dimness or haziness of 
vision. The fundus in such cases usually presents albuminuric retinitis 
and Bright's disease is present. Temporary or recurrent blindness in 
syphilitic involvement of the brain is sometimes a valuable early diag- 
nostic symptom of that condition and also of brain-tumor. Early cor- 
rection of the toxic state in the various poisonings usually promptly 
results in a return of vision, but the persistence of toxemia may induce 
permanent blindness. 

Excepting in the albuminuric cases, the fundus at first ordinarily 
presents nothing abnormal. Sometimes pupillary symptoms are absent ; 
sometimes there is dilatation and immobility. The difference seems to 
be due to the essential involvement of the cortical cells in the first case, 
and of the retinal cells, or of both, in the second. 

No attempt is made in the foregoing to exhaustively treat of the dis- 
eases of the visual tract and retina. The involvement of the second 
cranial nerve is commonly only a part of a neurological case, but has a 
symptomatic value of great importance. From this standpoint the various 
features that relate to diseases of the nervous system have been grouped. 



CHAPTER IV. 



DISEASES OF THE OCULAR NERVES-THE THIRD, 
FOURTH, AND SIXTH CRANIAL PAIRS. 

Anatomical Considerations. — The muscles of the eye are supplied 
by the third, fourth, and sixth cranial pairs and the sympathetic. The 
third, fourth, and sixth nerves arise from collections of cells ranged from 



DISEASES OF THE OCULAR NERVES. 



109 



before backward, under the posterior portion of the middle ventricle, the 
aqueduct of Sylvius, and the anterior angle of the fourth ventricle. 

They have in common the function of controlling the movements of 
the eyeballs. In addition, the third nerve governs contraction of the 
iris and the ciliary muscle, and elevation of the upper eyelid. The sym- 
pathetic, through the optic ganglion, dilates the pupil. Starting from 
before backward in the nuclei of the third nerve, we find represented (1) 
ciliary and then (2) pupillary contractions. The centers for the extrinsic 
ocular muscles follow presumably in the following order : The internal 
rectus, the superior rectus, the elevator of the eyelid, the inferior rectus, 
and the inferior oblique. The fourth nerve is distributed solely to the 
superior oblique, and its center is placed close behind those for the third 
nerve. At a little distance caudad under the floor of the fourth ventricle 
is the center for the sixth nerve, which controls the external rectus. All 
these centers are in close functional and anatomical relationship, and can 
reasonably be considered as a single mechanism, made up of three por- 
tions. The first is the iridociliary, the second embraces the centers for 
the muscles of convergence, and 
the third comprises the nucleus 
for the sixth nerve, which con- 
trols the external rectus, the 
only divergent ocular muscle. 
Ocular movements are also rep- 
resented in the frontal motor- 
cortex. The nuclear centers are 
connected with the higher levels 
through the motor radiations 
and the internal capsule. The 
muscles governed by the third 
nerve are also brought into re- 
lation with the orbicular mus- 
cles of the lids by nuclear con- 
nection with the facial nerve. 
The accommodation and light 
reflex are thereby correlated to 
the act of winking and the posi- 
tion of the palpebral curtains. 

Based upon the studies of 
Schaefer, Unverricht, Danillo, 
Munk, and his own experi- 
ments, Roux * asserts that the oculomotor apparatus has a double cortical 
representation ; first an anterior one at the foot of the second frontal 
convolution, and, second, a posterior center in the occipital region. Von 
Bechterew 2 also contends that irritation of the anterior margin of the 
occipital lobe in the dog produces narrowing of the pupil and increase 
of accommodative effort. 

The various ocular muscles serve to move the globe in the orbit in 
the directions indicated by their names ; but the superior and inferior 
recti, owing to the oblique direction from the apex of the orbit to their 

1 "Arch, de Neurol.," Sept., 1899. 2 "Neurolog. Centralblatt," May, 1900. 




Fig. 36.— Diagrammatic longitudinal section of the 
mid-brain, showing the relation of the nuclear centers 
for the ocular muscles (after Brissaudj. 



HO DISEASES OF THE CRANIAL NERVES. 

insertion, also draw the eyeball toward the nose and rotate it inward. 
This is counteracted by the oblique muscles and the external rectus, but 
the oblique muscles also act in convergence. Convergence of the eyes, 
necessary for all close vision, is thus much better provided for than the 
opposite action. Voluntary divergent squint is impossible. 

The motor nerves of the eye may be diseased (1) at their nuclear 
origin, (2) in their intracerebral course, (3) in their intracranial course 
from apparent origin to their cranial outlets, and (4) within the orbit. 
Four groups of symptoms are produced : (1) Pupillary variations, (2) 
disturbance of accommodation, (3) muscular incompetence and squint, 
(4) double vision. It is by the study of these symptoms, their mutual 
combinations, and the association or absence of other cerebral indica- 
tions that a distinctive and localizing diagnosis is possible. We will 
first consider the individual nerves. 

Ocular Palsies. — Complete division of the third nerve paralyzes all 
the extrinsic muscles but the external rectus and the superior oblique. 
The eye, in consequence, can be turned strongly to the outer canthus, 
and eventually becomes fixed in that position. The eyelid droops in 
complete ptosis, which the patient tries to remedy by the action of the 
frontalis. The pupil is widely dilated by the unopposed action of the 
sympathetic, and does not react for light or accommodation. The eye, 
unless strongly myopic, is incapable of near vision through the loss of 
accommodation due to paralysis of the ciliary muscle. There is double 
vision excepting when the sound eye is made to correspond with the 
direction of the one paralyzed. 

Division of the fourth nerve allows the eyeball at the top to slightly 
rotate outward on the anteroposterior axis, which corresponds practi- 
cally to the line of direct forward vision. When fixed in this position 
by the action of the inferior oblique and the inferior rectus, which act 
together, the rotation can sometimes be observed if carefully looked for, 
but the index to this paralysis is in the diplopia, to be studied later. In 



12 3 

f~\ £*\ f!& 




Mi *£' V - ^a»daHI 



Fig. 37.— Paralysis of the left third cranial nerve. 1, Ptosis; 2, ineffectual attempt of frontalis to 
overcome ptosis ; 3 shows partial ptosis and outward deviation of affected eyeball. 



attempts at downward convergent vision the inward rotation of the eye- 
ball fails to take place. 

When the sixth nerve is divided, the eye can not be turned outward 
from a line marking direct forward vision, and later the eye becomes 



DISEASES OF THE OCULAR NERVES. HI 

fixed in a strong inward squint that may carry the pupil to the internal 
canthus. The diplopia is marked. 

Destructive injury to the sympathetic produces great narrowing of the 
pupil, as the pupillary sphincter, innervated by the third nerve, escapes. 
At the same time the eyeball becomes prominent or slightly exophthal- 
mic by reason of the paralysis of Miiller's muscles and the retro-ocular 
turgescence. The pupil does not react for light or for pain. 

Diagnosis of Ocular Palsies. — When the lesion is complete and 
has existed some time, difficulty in deciding which extrinsic muscle is 
at fault is not very great. In partial lesions and when the condition 
is vacillating or slight in degree, a careful examination is required. We 
have two important indications — namely, the habitual position of the head 
and the diplopia. When an ocular muscle is weakened, the patient un- 
consciously and constantly so carries the head that the least possible 
work is required of the paretic muscle. For instance, if the right ex- 
ternal rectus is involved, the patient will turn the head to the right, 
thereby relaxing the injured muscle. The rule as laid down by Land- 
holt 1 is that the direction of the head corresponds in every way to the physi- 
ological action of the jxtralyzed muscle. 

If the extended lines of the visual axes for both eyes do not attain the 
same fixed point, diplopia results. The sound eye sees the fixed object 
clearly and the mind refers the image to the proper position in space. 
The divergent or convergent eye sees the fixed object indistinctly, as the 
image does not fall on the sensitive spot of the retina and the mind pro- 
jects it to a wrong position in space, — namely, to the position by experi- 
ence associated with the particular part of the retina in operation. In 
diplopia of long standing the mind learns to neglect the weaker, false 
image, and the patient may be unaware of his double vision. The eye also 
usually becomes more and more divergent, presenting the comparatively 
insensitive retinal periphery to the fixed object, and this assists in the men- 
tal neglect of its image. When the muscle weakness is very slight, diplo- 
pia only occurs on quick movements of the eyes or in extreme range of 
the eye in the direction of the affected muscle's action, and then it may 
be but momentary, the muscle under the stimulus of attention gradually 
drawing the eye into line. This is often accomplished in a jerky man- 
ner. The eyeball presents a number of oscillations which may termi- 
nate in the proper position, or the globe may swing back to the abnormal 
position, the muscle being quite exhausted. The double vision and the 
faulty projection at first invariably give rise to pronounced ocular vertigo. 

In examining a case of diplopia the first question is whether it is 
monocular. Closing one eye prevents double vision unless it is confined 
to the open eye, in which case, if not due to defective media or faulty 
curvatures, it is almost surely hysterical. Place the patient in a good 
light, have him hold the head motionless, and let him follow with both 
eyes the point of your finger through a circular range about a foot from 
his face. At some angle the two eyes will fail to maintain parallelism, 
or jerky movements of one eye may be noticed. The point is to determine 
which is the affected eye. Cut off the patient's line of sight from one eye 
with a card held at such a distance from it that its motion can still be ob- 
1 "Brit. Med. Jour.," Sept. 15, 1894. 



112 



DISEASES OF THE CRANIAL NERVES. 



served, and have the patient fix both eyes upon your finger in the direc- 
tion toward which conjugate movements failed. If the sound eye be 
covered, it will overact and be turned farther to the side than is re- 
quired. This overaction, or secondary deviation, is due to the fact that 
the stimulation necessary to draw the affected eye in the direction of the 
weak muscle is more than sufficient for the corresponding sound muscle. 
If you have covered the weak eye in the same way it will not move 
outward far enough when the finger is fixed by the sound eye, and for 
a similar reason. The direction of failure in the affected eye, therefore, 
points to the weakened muscle. In marked squint of this character 
the affected eye often presents a much wider range of motion when the 
sound eye is covered than when binocular vision is attempted. Appar- 
ently the volitional attempt is stronger when the muscle is not disturbed 





Fig. 39. 

Fig. 38. Convergent squint. The ray of light, a c, falls to the right of the sensitive spot, m, of 
the inturned left eye, L. Such stimulus has always been recognized by the mind as emanating from 
objects to the left, and not realizing the disordered position of the ocular globe a false image, e, is pro- 
jected an additional distance to the left, measuring from c as the operating sensitive spot, in the 
line d e. 

Fig. 39.— Divergent squint. The ray of light, a c, falls to the left of the macula, m, of the outwardly 
turned left eye, L. Such stimulus has always been associated with objects to the right, and the false 
image, e, is projected to the right, c, acting on the sensitive spot at the time. 



by two images. Overaction of the sound eye, however, occurs, as in 
the card-test. 

The diplopia test is made as follows : Place the patient facing a 
candle or bright object, such as a narrow strip of white paper the size of 
a lead-pencil, placed on a dark background at a distance of, say, twenty 
feet. Cover one eye with a red glass. If there is double vision, the 
red image corresponds to the covered eye. If the red image and the 
covered eye are on the same side, the diplopia is simple ; if on opposite 
sides, the diplopia is crossed. When the eyes converge, the diplopia is 
simple ; when the eyes diverge, the diplopia is crossed. Gowers' rule is : 
" When the visual lines, the prolonged visual axes, cross, the diplopia is not 



DISEASES OF THE OCULAR NERVES. 113 

crossed." If, now, the fixing object remaining stationary, the head be 
turned one way and another, — in some given direction the images will 
separate and in the opposite direction approach and perhaps fuse. 
Landholt 1 lays down this rule : " The affected eye is that in the direction 
of whose image the diplopia increases." For instance, in simple diplopia, 
the right image corresponds to the right eye. If the diplopia increases on 
looking to the right, the right eye is affected. In crossed diplopia the 
left image corresponds to the right eye. If the images separate on look- 
ing to the left, the right eye is at fault because its image corresponds to 
the direction of the increased diplopia. The same thing is true in 
vertical diplopia. 

He also lays down this rule : " The paralyzed muscle is the one ichich 
would give to the eye the direction of the false image." The false image, 
of course, belongs to the affected eye. For instance, in simple diplopia 
with the right eye affected, it is the external rectus that is at fault, as it 
is this muscle which would, if competent, direct the eye to the posi- 
tion of the false image at the right of the true image. Involvement 
of the oblique is similarly shown. If the patient indicates that the 
image of the right eye, in simple diplopia, is to the right and its upper 
end leans to the left, we know, by the application of this rule, that the 
right superior oblique is deficient. An opposite condition would point 
to the inferior oblique and inferior rectus, which operate together. 

The location of the lesion determines the distribution of symptoms 
and through them is clinically deciphered. A lesion involving the 
nuclei under the aqueduct of Sylvius is almost invariably attended by 
bilateral symmetrical eye conditions. This is due to the anatomical 
proximity of the centers on each side of the middle line and to their 
physiological relations. A lesion which destroys accommodation and 
pupillary contractions affects the most forward group of nuclei. If the 
middle group is involved, all the extrinsic muscles of the eyes are dis- 
abled, even the external recti, as this group has a controlling influence 
over the nucleus of the sixth nerve. If the lesion fall upon the sixth 
nucleus alone, double convergent squint is produced. In the same way, 
if some one or several of the conjugate movements of the eyes be lost, 
or a double ptosis is present, the lesion is nuclear unless movements of 
the head and trunk are lost at the same time. In such case the lesion 
is probably above the nucleus in the internal capsule or in the cortex. 

The three ocular nerves leave their grouped centers by widely 
diverging routes, and may be cut off separately and unilaterally by en- 
cephalic conditions, such as hemorrhage, inflammation, or new growths. 
Such lesions invariably implicate other structures, and give rise to 
numerous symptoms other than those referable to the ocular nerve. 
For instance, a lesion in the peduncle in the region of the red nucleus 
would disturb the motor tracts in the crus and produce paralysis on the 
opposite side of the body, with paralysis of the third nerve, ptosis, etc., 
on the same side as the lesion. This, by Charcot, is denominated the 
symptom group of Weber (fig. 36). 

1 hoc. cit. 



114 DISEASES OF THE CRANIAL NERVES. 

In basilar inflammations and injuries, and particularly in syphilitic 
meningitis, the ocular nerves are likely to be injured. The sixth, from 
its long and exposed course, is especially prone to injury and is the most 
frequently diseased nerve of this group. Lesions in this position are 
usually unilateral, and if bilateral differ, as a rule, in degree on the two 
sides. Here injury to the third nerve necessarily involves all its 
branches and functions. A lesion which could select from the nerve- 
trunk the pupillary fibers, for instance, is inconceivable. Diffuse cere- 
bral symptoms, such as headache, vertigo, nausea, stupor, convulsions, 
and optic neuritis, are also commonly present. At the apex of the orbit 
all the ocular nerves, with the ophthalmic division of the fifth and the 
optic nerve, are closely approximated. Injury or disease at this point 
would, therefore, determine complete internal and external ophthal- 
moplegia, impair vision, and give rise to sensory disturbances in the 
distribution of the supra-orbital nerve. Pressure at the same time on 
the return orbital circulation congests the retinal veins and produces 
some exophthalmos. After the nerves have separated in the orbit, any 
one or more of them may be injured by traumatism or local disease. 
Their branches may be singly selected. The diagnosis depends upon 
the muscles involved, and the anatomical relations of the nerves and 
their branches within the orbit. 

Causes of Ocular Palsies. — The conditions which give rise to 
palsies of the ocular muscles are very numerous. In the orbit trauma- 
tism and new growths are frequently causal of the loss of ocular move- 
ments. A blow over the eye is sometimes followed by paralysis of the 
levator palpebral superioris. Exposures to cold and the rheumatic states 
are sometimes followed by an ophthalmoplegia, which is probably due to 
a peripheral neuritis. This form may be present in multiple neuritis 
from alcohol, and probably from other poisons, and may involve few or 
many of the muscles. Orbital growths usually are marked by exoph- 
thalmos. Cervical, maxillary, and cranial tumors may invade the orbit 
and there produce these local symptoms. 

In their basilar course the motor nerves of the eye are frequently 
injured by meningitis, and especially by syphilitic disease. Basilar 
fracture, carotid aneurysm, or the pressure of neighboring intracranial 
growths may also implicate them in this locality. 

At the nuclei multiple sclerosis, bulbar palsy, polioencephalitis supe- 
rior, and locomotor ataxia frequently cause ocular palsies. A tempo- 
rary ptosis or diplopia is often an early symptom of tabes, and should 
always arouse suspicion of it or of syphilis. The exact mechanism and 
location of the tabetic disturbance which produces the Argyll-Robertson 
phenomenon is not understood, but presumably the anterior cell-group, 
controlling pupillary and ciliary contractions, is involved. In myas- 
thenia gravis various ocular deviations and a marked tendency to 
ptosis are encountered. 

A peculiar periodically recurring or relapsing palsy of the third nerve 
is sometimes encountered. It is more frequent in females, involves only 
one eye, lasts from one to six months, and returns at regular intervals, 
often during the entire life of the patient. Its pathology is not known, 



DISEASES OF THE OCULAR NERVES. H5 

but the nerve-trunk has several times been found to be diseased. Traces 
of this palsy, in some cases, can be detected during the intervals of prac- 
tical freedom from the trouble. It has been attributed to hysteria in 
certain instances, and is frequently associated with migraine, the so- 
called ophthalmoplegic migraine. 

Lesions of the cortex or of the internal capsule producing hemiplegia 
are often attended by conjugate deviation of the head and eyes toward 
the sound side of the body, but if the paralyzed side present convul- 
sions due to cerebral irritation, the eyes are then spasmodically drawn to 
that side. A lesion lower down in the pontine region would be marked 
by a crossed deviation, the eyes looking to the paralyzed side of the 
body, and in convulsions turning to the sound side of the body. 

Ocular Muscle Spasms. — The ocular muscles are usually associated 
with the other muscles in generalized convulsions, the eyes turning to the 
side most vigorously affected. Individual muscles alone are affected in 
very rare instances. The levator or a rectus may thus be spasmodically 
involved for years. Sometimes the ocular muscles participate in facial 
tics and spasmodic torticollis. In hysteria the eyes are frequently rolled 
upward and outward, or strongly converged during convulsive manifes- 
tations of the disease, and these ocular positions may remain for long 
periods of time after the convulsion has subsided. A more common eye 
condition in hysteria is one of spurious double ptosis. It is really a spasm 
of the orbiculares. The patient apparently tries to overcome it by raising 
the brows with the frontalis. An attempt to raise the lids with the finger 
at once develops resistance, which in paralytic ptosis is never present. 

Nystagmus consists in rapid rhythmical involuntary oscillations of 
both eyeballs, due to spasmodic action of the ocular muscles. When 
both eyes are affected, the movements are similar and synchronous. The 
spasmodic movements are commonly horizontal, less frequently rotary, 
and only rarely vertical. When the eye vibrates in one plane, it ordinarily 
moves outward quickly and more slowly returns. The oscillations vary 
in number from fifty to two hundred or more a minute, and in extent 
from one to ten millimeters. In uremic coma the eyes will sometimes 
be noticed in a rhythmical movement which carries them through their 
widest lateral range about ten times a minute. Xystagmus may be 
constant or only provoked by calling forth a particular movement of 
the eyes, as by directing them upward or outward. This latter must 
not be confused with the jerky, unrhythmical, and momentary move- 
ments of weakened muscles. Bar any claims that in about one-half 
of all normal persons strong lateral deviation of the eyes is attended 
by slight nystagmoid movements, but these are about equal for all 
extreme angles of vision. In the nystagmus of labyrinthine disease the 
movements are of unequal rapidity and are intensified in looking in the 
direction of the quicker movement. In organic disease of brain and 
cerebellum the nystagmic movements are persistent and practically of 
equal rapidity in each direction. 

The causes and significance of nystagmus are often obscure. It may 
be acquired as the sequel of any condition which greatly impairs vision. 
Corneal and lenticular opacities, choroiditis, and retinitis may precede it, 



116 DISEASES OF THE CRANIAL NERVES. 

especially if occurring in childhood. Albinos frequently present nys- 
tagmus. Miners who work in cramped positions with poor illumination 
acquire it, probably as a fatigue neurosis through the overstrain of cer- 
tain eye-muscles in attempting to keep the work in view. In them it 
is often only present when the particular attitude which their work 
requires is assumed. 

Nystagmus is present incidentally or regularly in a long list of ner- 
vous diseases which have neither location nor pathological anatomy in 
common. It is almost a cardinal symptom in insular sclerosis and in 
hereditary ataxia of the Friedreich type. It is common in cerebellar 
tumor and tumors involving the corpora quadrigemina and optic thalami. 
Occasionally it attends sinus thrombosis, meningitis, meningeal hemor- 
rhage, and variously seated cerebral hemorrhages, softenings, and 
tumors. Hysteria has also furnished rare cases of persistent nystagmic 
ocular spasm. It is closely associated with auditory diseases affecting 
the labyrinth and often attended by vertigo and tinnitus aurium. (See 
Diseases of the Eighth Cranial Nerve, Chap. VII.) 

The treatment of ocular palsies depends upon the causal con- 
dition and is often most unsatisfactory. New growths and traumata are 
surgical conditions for the most part. Syphilitic palsies may readily 
yield to treatment, whether due to basilar or central involvement, but 
only too often recur, yield again, and finally become permanent. The 
neuritic form is treated as a part of the general intoxication usually at 
the bottom of the disease. A persisting ocular deviation is often bene- 
fited by a tenotomy. Muscle cutting should always be preceded by 
exercise of the muscles with prisms, which sometimes is helpful, and by 
general treatment. Nystagmus, excepting in the unusual cases where it 
is due to meningeal and sinus diseases, or other curable lesion, is prac- 
tically unyielding to all measures. Miners' nystagmus usually ceases 
when the occupation is changed. 



DISEASES OF THE TRIFACIAL NERVE. 



117 



CHAPTER V. 

DISEASES OF THE TRIFACIAL NERVE. 

Anatomical Considerations. — The fifth nerves represent the sen- 
sory portions of all the motor cranial nerves. Their sensory distribution 
embraces most of the skin of the head and face, all their mucous mem- 
brane-lined cavities, and the cerebral meninges in part. The exact 
limits of this sensory field have been worked out by Cushing in a 
number of cases subjected to extirpation of the ganglion of Gasser, and 
are shown in Fig. 39 A. In addition, through at least the chorda 
tympani, the fifth subserves the special sense of taste. Its small 




Fig. 39 A. — Diagram showing the normal (average) field of postoperative cutaneous anesthesia. 
The shaded area, including tragus and anterior wall of meatus, remains anesthetic to tactual (hair esthe- 
sionieter) stimuli. The dotted strip gives the impression of touch or pressure to pain stimuli (needle), 
with few if any actual pain points (Cushing, in Bull. Johns Hopkins Hosp., July-Aug., 1904). 



motor root innervates the mandibular muscles of mastication. The 
nuclear origin of the fifth nerve in the medulla is correspondingly 
extensive. The smaller motor nucleus is situated under the floor of the 
fourth ventricle near its lateral angle, with an upward extension as high 
as the corpora quadrigemina. Outside of this is the larger sensory 
nucleus, which is connected continuously with nuclear gray matter as 
low as the fourth cervical spinal segment. These centra are brought 
into relation with the cerebellum and with the cerebral cortex by 
upward radiations. For the motor portion the cortical centers are at the 
foot of the anterior central convolution. The sensory cortical repre- 



118 



DISEASES OF THE CRANIAL NEB VES. 



sentation is not clearly known. The sensory and motor trunks leave 
the surface of the pons separately, though side by side, and only after 
the sensory portion has passed through the Gasserian ganglion does the 
motor trunk join the third trigeminal division. 

According to Gowers and others, the strictly gustatory portion fol- 
lows a most extraordinary course before, as the chorda tympani, it 
reaches the lingual nerve and is distributed to the anterior portion of 
the tongue. At first contained in the sensory root, it apparently passes 
from the Gasserian enlargement with the middle or superior maxillary 
branch. Thence it drops into the sphenopalatine or Meckel's ganglion, 
and turns backward in the form of the Vidian nerve, to penetrate the 
petrous portion of the temporal bone and join the facial nerve in the 
Fallopian aqueduct. It follows the facial nearly to its exit at the sty- 
lomastoid foramen, where it turns shaprly upward, reaching the tym- 
panic cavity, which it leaves by the Gasserian fissure. It then de- 




Fig. 40.— Distribution of the sensory cutaneous nerves on the head : V 1} V 2 , V3, The three branches 
of the trigeminus ; at, auriculotemporal; so, supraorbital; st, supratrochlear; it, infratrochlear ; I, lac- 
rymal; m, mental; b, buccinator; am, auricular is magn us ; sm, subcutaneous malse ; oma, occipitalis 
major ; omi, occipitalis minor ; cs, superficial cervical (after Hirt). 

scends between the pterygoid muscles and joins the lingual branch of 
the inferior maxillary or third trifacial division, to be distributed to the 
anterior portion of the tongue. The base of the tongue and faucial 
pillars also recognize taste impressions. It is supposed that these sensa- 
tions reach the trunk of the fifth by way of the glossopharyngeal nerve 
through connections with Meckel's ganglion. We know certainly that 
division of the sensory root of the fifth abolishes all taste sensation on 
the corresponding side of the tongue at least temporarily, but Cushing, 1 
after an elaborate study of twenty-six cases of extirpation of Gasseris 
ganglion, believes that the sense of taste ultimately returns to the tongue, 
and that the gustatory path is not by way of the fifth nerve. His ob- 
servations are confirmed by Davies, 2 and the exact course by which the 
gustatory sensations reach the brain is undetermined. 

1 "Johns Hopkins Hosp. Bull.," July- Aug., 1904. 2 " Brain," 1907. 



DISEASES OF THE TRIFACIAL NERVE. 



119 



Cortical Diseases of the Fifth Nerve. — Lesions of the portion 
of the motor cortex associated with the fifth nerve produce spasm or 
paralysis according as the lesion is irritative or destructive. The 
involved muscles are the pterygoids, the temporal, and the masseter. 
In generalized convulsions they are ordinarily involved. Very rarely 
they are the sole seat of motor disturbance presenting a masticatory 
spasm or paralysis. The spasm may be tonic, as in trismus, or repeated 
at varying intervals. The teeth are tightly clenched, and the masse- 
ters and temporals stand out firm and hard. In the clonic variety, 
as in the chattering of a chill, the lower jaw is sharply moved laterally 
or vertically. Vigorous grinding of the teeth may be present. This 
is sometimes seen in the late stages of paretic dementia and in other 
wide-spread organic brain disease. Single or repeated spasms may have 
their origin in local disease of the jaws, such as periosteitis or tooth- 
ache, and are then reflexly produced. 

Masticatory paralysis of cortical origin is extremely rare. The 
cortical lesions have almost invariably been found to be bilateral, but 




Fig. 41.— Case of nuclear disease of the fifth cranial nerve in a ease of tabes, showing area of cutaneous 
analgesia; some facial atrophy is also present. 



Hirt 1 has reported a case of complete mandibular palsy due to a left- 
sided lesion at the foot of the ascending frontal convolution. 

Nuclear disease of the fifth nerve is usually a part of a group of 
bulbar symptoms. Masticatory paralysis arising from this source is ex- 
tremely rare. Progressive bulbar palsy and pontine tumors may cause 
it, but other cranial nerves are almost invariably affected at the same 
time. Multiple sclerosis and tabes may and often do affect the fifth 
nucleus, causing bilateral sensory and motor symptoms in the area of 
its distribution. 

Peripheral intracranial affections of the trigeminus may involve 

the stem, the Gasserian ganglion, or the three branches of the nerve at 

their exits from the skull. The differential diagnosis as to location may 

be impossible if adjoining nerves or structures are uninjured or present 

1 "Berlin, klin. Wochens.," 1887. 



120 DISEASES OF THE CRAXIAL XERVES. 

no indications. A description of the symptoms arising from injury to 
the trunk will therefore apply to disease of the Gasserian ganglion or 
of the three branches at their cranial exits. Growths and inflammatory 
processes are the usual causes of this form of trifacial disease. 

The motor symptoms are those of paresis or paralysis of the mandib- 
ular muscles. The jaws can not be closed or can not be firmly held 
together when closed. The combined strength of the jaw-muscles is 
immense, and considerable impairment may go unnoticed. In complete 
bilateral paralysis the jaw droops, but can at first be raised by the action 
of the facial muscles, especially the buccinators and orbicularis oris. 
If the palsy is one-sided, the jaw may still be raised by the unilateral 
action of the uninjured side, but the bite is feeble. Attempts to bring 
the paralyzed pterygoids into play fail to produce grinding movements, 
so that the jaw can not be forcibly advanced from the impaired side or 
thrust in the opposite direction. In long-standing cases contracture in 
the muscles which depress the jaw may permanently hold the mouth 
open. 

Interference with sensation may be partial or complete. In the lat- 
ter case all parts of the face, head, nasal fossa?, conjunctivae, mouth, and 
tongue supplied by the fifth nerve are insensitive, and taste is abolished 
on that side of the tongue and oral cavity. The sneezing reflex is 
abolished on the anesthetic side, as well as the gagging reflex caused 
by irritating the soft palate. Instruments may be passed into and 
through the nasal chambers without eliciting sensation, and ammo- 
nia fumes, etc., no longer cause irritation. Prodromal pricking, ting- 
ling, and burning usually precede the anesthesia. Frequently, when the 
loss of sensation is pronounced, so that the patient no longer feels a pin- 
prick, complaints are made of pain and burning in the anesthetic area, — 
ansesthesia dolorosa. In one case observed by the writer, while general 
sensation was abolished in all its modes and tenses, muscular sense re- 
mained. A touch or prick was not perceived, but the slightest motion 
communicated to any facial muscle was instantly recognized, apparently 
through the uninjured seventh nerve. Trophic disturbances are the rule, 
but, ordinarily, they are slight in degree. The insensitive conjunctiva 
and cornea are easily irritated and prone to ulceration that may reach a 
destructive grade. The nasal and lacrimal secretions are defective 
and the mucous membrane dry. In the nose this dryness impairs the 
sense of smell. The paralyzed side of the tongue is thickly furred, 
due partly, but not wholly, to the fact that food is only chewed on the 
sound side. The salivary secretion may be greatly diminished. Herpetic 
eruptions in the cutaneous distribution are frequent, and when the gan- 
glion or branches are diseased and the conjunctiva is involved, constitute 
a serious feature, as ophthalmia and complete loss of the eye may ensue. 

Facial hemiatrophy may follow injury and disease of the fifth nerve. 
In this rare deformity the wasting is always limited to the distribution of 
the trifacial, and is usually most intense in the field of the middle and in- 
ferior divisions. The alleged causes in numerous instances, such as blows 
on the head and face, infectious fevers, exposure to cold, facial erysipelas, 
osteitis of the jaws, etc., are capable of seriously influencing the nerve. In 
several cases histological changes in the trunk, ganglion, or branches have 



DISEASES OF THE TRIFACIAL XERVE. 121 

been demonstrated, and atrophy has followed division of the root of the 
trigeminus in man and animals, Touche 1 has reported lesions in the pons 
affecting the root of the fifth nerve, and in another case the sole lesion was 
in cortex and pia of the operculum. Jacquet has demonstrated a lesion of 
the third cervical sympathetic ganglion, and many assume that the sym- 
pathetic is alone at fault. On the other hand, Grabs 2 reports a marked 
case without the slightest discoverable change in the nervous system. 

Clinically, it may begin in a widening sclerodermic patch on the 
side of the face, but more commonly the entire half of the face gradually 
diminishes. The loss affects both dermal and osseous structures and 
less markedly the muscles, which may escape entirely. The opposite 
side of the face may finally become involved, though this is rare. The dis- 





L 

Fig. 42. — Two early cases of facial hemiatrophy. 

ease develops usually before adult life, but may appear at any age. It 
produces a most notable difference of appearance on the two sides. The 
atrophic half lacks the proportions of the sound side in every particular. 
The condition is usually most marked in the lower portion of the face, 
gradually lessening upward sothatthe brow may show almost no discrep- 
ancy on the two sides. The skin is thinned notably, sometimes to a half 
or quarter of its proper thickness; the muscles are sometimes reduced in 
size and strength ; the lower jaw may be a third smaller on the affected side. 
The teeth are often lost. As the skin is closely applied to the muscles and 
the bony conformation, a cadaverous appearance is presented that may be 
strikingly at variance with the plum]), healthy side, and is sometimes 
sharply marked by a furrow at the middle line of the brow and chin. The 
nose, chin, and mouth deviate to the affected side. TThile the orbital and 
palpebral structures are frequently wasted, the eyeball is affected only in 
rare cases, but has been observed wasted and even destroyed. The dis- 
ease is progressive for years, but may come to a standstill at any time, 
and again advance. It seems to be unmodified by treatment, but the 
continuous use of thyroids may be tried with some prospect of retarding 
the progress of the wasting, especially in those cases showing sclero- 
1 ''Neurol. Centralb.," June 16, 1914. 2 "Rev. neurologique, " 1902. 



122 



DISEASES OF THE CRANIAL NERVES 



derma. Paraffin has been injected in a number of instances to restore 
the contours of the face purely for cosmetic effect. 

Disease of the trifacial branches is extremely common. Their 
course through bony channels, serving to protect them admirably under 
ordinary conditions, exposes them to pressure from inflammatory states, 
to injury by concussing blows, and to laceration from fractures involving 
the cranial and facial bones. Their proximity to the nasal, buccal, and 
pharyngeal cavities, always containing the potential factors of infection, 
is a local disadvantage. Finally, they are distributed to the most ex- 
posed portion of the cutaneous expanse, where, thinly covered, they rest 
upon unyielding structures. 

They are very often the seat of neuralgic pain, which will be more par- 
ticularly considered in the section on Symp- 
tomatic Disorders of the Nervous System, 
Part VIII. It is probable, however, that a 
nerve, the seat of long-continued neuralgic 
pain, symptomatic, perhaps, of a general blood 
state, — as malaria, for instance, — may even- 
tually become histologically changed and or- 
ganically diseased. A neuritis may be thus 
established which is usually marked by 
sharply-defined anatomical areas of hyper- 
sensitiveness or anesthesia. Dystrophic 
changes in the dermal structures, such as scal- 
iness, herpes, and falling or discoloration of 
the hair of the eyebrow and beard, are fre- 
quently encountered. The glands supplied by 
the given nerve over- or underact as the con- 
dition in the nerve is irritative or destructive. 
Neuritis may also be set up by extension from 
a neighboring inflammation in the orbit, an- 
trum, or jaws. The dental branches are par- 
ticularly liable to infection, injury, and irrita- 
tion, which in the case of molar teeth is not infrequently the cause of 
pain referred to other branches of the trifacial than the one immediately 
concerned. 

Injury to the lingual branch of the third division of the fifth nerve, 
if it occurs below the junction of the chorda tympani, produces loss of 
taste on the anterior portion of the tongue on the same side, in addition 
to the loss of general sensation and trophic disturbance in its anatomical 
area of distribution. 

The motor fibers of the trifacial, being entirely confined to the third 
division, suffer with it. Paresis or paralysis of the muscles of mastication 
on the same side follows. The prominence and hardness of the masseter 
and temporal do not take place when the patient attempts to clench the 
teeth, and deviation of the chin to the opposite side can be but feebly pro- 
duced or is lacking. Destruction of the motor root, either above or below 
the ganglion or at the bulbar nucleus, gives rise to muscular atrophy in 
the muscles of mastication, and to the reaction of degeneration upon their 
electrical stimulation. A cortical lesion causes no such degeneration. 




Fig. 43. 



-Case of facial hemiatrophy 
(after Yonge). 



DISEASES OF THE FACIAL NERVE. 



123 



CHAPTER VI. 
DISEASES OF THE FACIAL NERVE. 

Anatomical Considerations. — The seventh cranial nerve has its 
cortical origin or representation in the lower Rolandic region. The 
nuclear center is situated under the floor of the fourth ventricle, to 
the inner side of the ascending root of the fifth nerve. The path- 
ways between nuclei and cortex decussate in the median raphe (Ed- 
inger). Erom the nuclear cells the nerve passes close to the nucleus 
of the sixth nerve, and, descending thence through the pons, emerges 
in the furrow between the pons and 
medulla outside the sixth nerve, closely 
accompanied by the eighth or audi- 
tory nerve, with which it proceeds di- 
rectly to the internal auditory meatus. 
Its relation to the sixth nucleus and 
its proximity to the sixth nerve on 
emergence explain the frequent asso- 
ciation of these nerves in disease. The 
parallel course of the auditory and 
facial from medulla to meatus explains 
why meningeal and basilar conditions 
of necessity affect them both at the 
same time. 

The nucleus of the seventh re- 
ceives fibers from the oculomotor nu- 
clei above, which are destined to the 
orbicular muscle of the eyelids. By 
this mechanism the functions of wink- 
ing, accommodation, and ocular move- 
ments are associated. Fibers from 

the hypoglossal nucleus below also pass to the nuclear centers of the 
seventh, and are eventually distributed to the orbicular muscle of the 
mouth, correlating the labial and lingual movements necessary in 
phonation, mastication, and other buccal processes. 

The decussation of the seventh explains the phenomena of crossed or 
alternate paralysis of the face and limbs. A lesion in the pons above 
the decussation involves at once the seventh nerve and the pyramidal 
tract for the opposite side of the body, but below the facial crossing and 
above the pyramidal decussation a lesion involves the face on the same 
side and the limbs on the opposite side. Such a lesion must involve 
the lower third of the pons, approximately the portion below the super- 
ficial origin of the fifth pair. 

After entering the internal auditory meatus the seventh nerve bends 
somewhat sharply, and presents a gangliform swelling, which receives the 
large superficial petrosal from the Vidian nerve, probably containing the 
taste-fibers from the second branch of the fifth nerve by way of the spheno- 
palatine ganglion. The taste-fibers leave the facial nerve in the form of the 




Fig. 44. — Diagram showing the course 
of facial and pyramidal fihers and the re- 
lations of cranial nerve-trunks. A, Le- 
sion causing one-sided symptoms ; B, lesion 
causing crossed paralysis of the face on one 
side and the limbs on the other. 



124 



DISEASES OF THE CRANIAL NERVES. 



chorda tympani after it has almost completely traversed the Fallopian canal, 
and, passing up through the tympanum, finally reach the anterior portion 
of the tongue with the lingual branch of the fifth. Within the Fallopian 
canal the facial gives off from within outward, first, near the ganglion of 
the knee, above mentioned, a motor branch to the tympanic plexus; sec- 
ond, a motor branch to the stapedius muscle; and, third, the chorda accom- 
panied by a secretory branch 
to the salivary glands. The 
facial nerve, therefore, within 
the aqueduct contains (1) motor 
filaments for the facial muscles, 
(2) filaments of the special 
sense of taste for the anterior 
two-thirds of the tongue, (3) 
motor filaments for the internal 
ear, and (4) secretory fibers for 
the salivary glands. In addi- 
tion there are a few filaments 
subserving common sensation 
for the external ear, derived 
from the fifth nerve, which 
pass with the facial to its 
exit. 

After leaving the stylomas- 
toid foramen the facial gives 
off (1) the sensory branches 
above referred to, (2) branches 
to the external auricular mus- 
cles, and (3) branches to the 
posterior portion of the occi- 
pitofrontalis. The trunk in 
the substance of the parotid 
then divides into (4) widely 
spread branches supplying 
motion to all the muscles of 
the face, to the platysma, the stylohyoid, and the posterior belly of the 
digastric. 

Practically, the seventh nerve may be considered one of pure motion. 
It furnishes the trophic supply to the muscles of the face. The sensory 
and secretory filaments merely join it during its course and leave it 
before it reaches its periphery. When it is diseased the major symp- 
toms are motor and consist of increased or decreased activity, giving rise 
to facial spasm or facial palsy as the condition is one of irritation or 
deficit, The muscles also waste. The addition of sensory and secretory 
disturbances enables us to locate the lesion with more or less exactness. 
Spasmodic Affections of the Facial Nerve. — Facial Spasm.— 
Irritative lesions in the Kolandic face-centers may set up grimacing 
spasms on the opposite side, usually of an unrhythmical, clonic sort, 
which are not suggestive of any intention. Such a spasm may be 
the initial feature of a Jacksonian fit. Grimacing is the feature of 




Fig. 45.— Diagram of facial nerve passing through 
the petron. F, Facial ; A, auditory ; St. F. stylo- 
mastoid foramen; Ch, chorda; S, S, salivary fibers; 
G, G, gustatory fibers; St, branch to stapedius mus- 
cle ; T, tympanic branch. 



DISEASES OF THE FACIAL NERVE. 125 

all severe epileptic attacks that most impresses onlookers. In limited 
cortical lesions in the face-centers the spasm may be confined to a por- 
tion of the face, as to the angle of the mouth or to the eyelids and brow. 
These cortical spasms are usually attended by mental symptoms, such as 
an aura, confusion, or unconsciousness, and are practically independent of 
circumstances and surroundings. Feelings of apprehension and a dis- 
tressed appearance commonly attend them. Their frequency is variable. 
Often they occur singly, at long and irregular intervals. An explosion, 
a sort of status, may take place so that the face is convulsed for many 
minutes or even hours, and then returns to a normal quietude, perhaps 
marked by a slight paresis or even by a distinct weakness, Avhich is im- 
portant and should always be sought. 

The irritative lesion may be subcortical and produce the same con- 
ditions. At the nuclear level it would almost certainly involve other 
cranial nerves. Pontine and basilar growths have in rare instances 
been the cause of such facial spasms, and inflammatory invasion of the 
nerve-trunk is usually marked by twitchings in the muscles which sub- 
sequently present palsy. These twitchings often reappear with regenera- 
tion. All the above conditions produce a pure spasm. 

The muscles supplied by the facial nerve, either alone or more 
commonly in conjunction with other groups, may be affected by spas- 
modic tics, including blepharospasm, mimic spasm, grimacing, etc. These 
are ordinarily the external manifestation of a fixed idea, and will be 
described under the psychoneuroses in Part VII. 

Paralysis of the Seventh Nerve. — Facial palsy follows lesion of 
the seventh nerve at any point from the cortex to the stylomastoid fora- 
men. In the face individual branches may be injured, with corre- 
sponding local motor loss. The most complete facial paralysis depends 
upon injury to the nerve-trunk. When it follows exposure to cold or 
occurs in rheumatic conditions it is often called BeWs palsy. The per- 
ipheral form, due to a lesion of the nerve-trunk after its entrance into 
the petron through the internal meatus, will first be considered, and then 
the nuclear and central varieties. 

Peripheral Facial Palsy. — Etiolog-y. — The facial nerve in the 
petrous canal is occasionally invaded by inflammation extending from 
the tympanic cavity. The separating plate of bone is often of extreme 
thinness, and may even be lacking, especially in children. Mastoid 
disease and pharyngeal inflammations have led to the same result. 
Fractures of the cranial base very frequently involve the petron, and 
may cause a facial palsy at once ; or this may come on from inflam- 
matory reaction after a few days, or later from the deposition of 
callus. In extremely rare instances hemorrhage within the canal pro- 
duces paralysis almost instantly. In some infantile cases a cerebellar 
hemorrhage invades the canal with the same result. Injuries to the 
nerve at its foramen of exit, as by blows with sharp or blunt instru- 
ments and by the obstetrical forceps, may cause the palsy. In addition 
to the local disadvantage presented by the facial nerve being surrounded 
by a long bony passage, Neumann attributes much to the large number 
of lymphatics and lymphatic glands encircling it at its exit from the 
stylomastoid foramen. Stagnation of lymph here favors changes in the 



126 DISEASES OF THE CRANIAL NERVES. 

neighboring nerve-trunk. Upward extension of inflammation in the 
parotid or side of the neck into the canal is an occasional cause. By all 
odds the most common and usual cause is a neuritis due to cold, as by 
a draft of air on the side of the face during the night, or from an 
open window, or after prolonged outdoor exposure. The nerve-swelling 
to which this gives rise nips the nerve in its unyielding channel and 
paralysis supervenes. The degeneration is found throughout the rami- 
fication of the nerve and ascends to the geniculate ganglion. The cells 
of the facial nucleus present varying stages of chromatolysis. 

Huebschmann, 1 from a series of 135 cases, found seventy-five per 
cent, to be of the so-called rheumatic form, nine per cent, due to ear dis- 
ease, and six per cent, to injury. Most of the rheumatic cases occurred 
between the ages of ten and forty years. Males predominated very 
slightly. 2 Reik 3 believes that the so-called rheumatic variety of facial 
palsy is very commonly dependent upon catarrhal or other inflammation 
of the middle ear, and urges an examination for otitis mediain every case. 

Any general depression of the physical state may act as a predis- 
posing element. In this relation rheumatism occupies a chief place. 
Anemia, syphilis, tuberculosis, and alcoholism are also very favoring 
conditions, as is the puerperium. Syphilis may of itself cause a local 
lesion, but must at this location act very exceptionally. Gouty and 
leukocythemic neuritis may also involve the facial trunk directly. 
Sarbo * agrees with Neumann that there is commonly a personal pre- 
disposition to facial paralysis, and Arkwright 5 reports six cases in two 
families which indicate the same thing. 

Symptoms. — Motor. — In a well-marked case, unless due to direct 
violence, within about twenty- four hours after the action of the inciting 
cause a little twitching in the affected side of the face is frequently noticed. 
Perhaps friends then first call attention to the distortion of the face, which 
in all expressional movements is drawn to the opposite side. The patient 
may first find that he is unable to expectorate with certainty, to whistle, 
or to puff out his cheeks and lips, owing to the loss of control over the 
labial positions. In two or three days the deformity is noticeable to 
all. The entire side of the face is affected, with the occipitofrontalis. 
Even the small muscles of the external ear on the same side are para- 
lyzed. The unopposed muscles of the sound side draw the mouth in 
their direction, and the zygomatici elevate its angle. When the mouth 
is opened widely it presents an unsymmetrical outline. It is higher on 
the sound side and displaced toward this side. This may mechanically 
cause the projected tongue to deviate to the sound side, but if the mouth 
be passively held in a median position, the lingual curve disappears 
and full mobility of the tongue can be easily shown. The dorsum of the 
tongue is slightly depressed on the affected side, according to Schultze, 6 
from weakness of the stylohyoid and digaster. Saliva and food ac- 
cumulate in the flabby cheek and have to be displaced with the finger 

i " Neurol. Centralblatt," Nov. 15 and Dec. 1, 1894. 

2 Waterman, " Journal Nervous and Mental Diseases," Feb., 1909. 

3 "Johns Hopkins Hosp. Bull.," April, 1902. 

4 "Dent. Zeit. f. Nervenhl.," Mar., 1904. 5 "Lancet," Jan. 23, 1904. 
6 "Munch, med. Wochens.," June, 1897. 



DISEASES OF THE FACIAL NERVE. 



127 



Mastication, therefore, is mainly done on the sound side and, due largely 
to this fact, lateral furring of the tongue on the paralytic side may ap- 
pear. Often there is some diminution of salivary flow on the paralyzed 
side, owing to the involvement of the secretory fibers which traverse 
the facial trunk. The nasolabial fold disappears on the injured side 
and is accentuated on the sound side. The chin and nose may deviate 




Fig. 46.— Facial palsy of left side. 1, Bilateral attempt to raise eyebrows; 2, bilateral attempt to close 

eyes; 3, smiling. 

to the sound side. The platysma on the same side is invariably involved. 
The eye on the paralyzed side can not be closed nor the eyebrow lifted. 
In attempts to close the eyes the eyeball on the affected side turns up- 
ward and can not be controlled. Winking is absent, and in the aged the 
lower lid often droops away from the ball. The cross-wrinkles on the 
forehead stop abruptly at the middle line. 




Fig. 47.— Facial palsy of left side. 4, forced effort to uncover teeth on both sides ; 5, protruded 
tongue in middle line ; 6, mouth open more widely on sound side in bilateral effort. 



During moments of quiet little asymmetry may be apparent, but the 
slightest emotional or voluntary movement produces and accentuates all 
the motor symptoms. In young patients, where the expressional lines and 
wrinkles are absent or only slightly developed, the difference between the 
two sides is much less marked than in those of more mature years. The 
greater resilience of the skin and the larger adipose layer contribute to 



128 DISEASES OF THE CRANIAL NERVES. 

this effect. The reaction of degeneration is present in the muscles either 
in complete or modified degree. The muscle reflexes are abolished and 
McCarthy's supra-orbital reflex is lost. After a few weeks the muscles 
viaste. The atrophic loss is not readily seen except in thin people. 
As the eye can not be closed, the exposed conjunctiva is often 
irritated and painful. At night it may become quite dry, and con- 
junctivitis of a severe grade may develop. From the relaxation of the 
lids the natural flow of tears to the lacrimal duct is interrupted and they 
overflow on to the cheek. In rare severe cases there is a herpetic eruption, 
but this is probably due to a simultaneous affection of the fifth nerve. 

Disturbance of common sensation is slight or wanting. If in the first 
week the muscles of the cheek be grasped, some tenderness can be elicited, 
which is probably due to the irritation of the sensory twigs distributed to 
the degenerating facial branches. The sense of taste on the same side of 
the tongue in its anterior two-thirds, the part supplied by the chorda tym- 

pani, is often disturbed or 
abolished. Many patients 
during the first few days ac- 
knowledge subjective taste 
sensations of a peculiar sort; 
but ordinarily a careful 
search must be made in order 
to elicit the actual difficulty. 
Hearing is sometimes modi- 
fied in such a way that low 
notes are more readily heard 
than on the sound side, while 
those of high pitch, as the 

Fil^Fac^alsy^^de^^ect^rTdism^n^und ticking of a Watch, are llOt 
side ; 8, non-effect of same current on paralytic side. distinguished With even Or- 

dinary acuteness. Middle- 
ear inflammation, if present, would be attended by some general loss of 
hearing and sometimes by tinnitus. 

In rare instances a double facial palsy is encountered. This usually is 
significant of intracranial disease, as pontine lesions, inflammation (espe- 
cially of a syphilitic sort) at the base, or nuclear degeneration, which ordi- 
narily involves other cranial nerves at the same time. A double otitis 
may produce it, or it may be part of a multiple neuritis, such as follows 
diphtheria and other general intoxications. In bilateral palsy the face 
hangs flabby, motionless, and without expression. The unwinking eyes and 
the drooping mouth give a vacuous look that is suggestive of dementia. 
All of the paralytic symptoms are present on both sides, but the distor- 
tions and asymmetry so prominent in the ordinary form are wanting. 

Course. — The tendency of the palsy to improve in peripheral facial 
paralysis is marked, excepting in destructive lesions of the nerve-trunk. 
Cases that improve get practically well in from three weeks to eighteen 
months, depending upon the amount of injury done the nerve and the 
duration of pressure within the facial canal. This is true regardless of 
treatment in those cases that depend upon so-called rheumatic condi- 
tions, though improvement may without doubt be accelerated by proper 




DISEASES OF THE FACIAL NERVE. 129 

management. The early loss of faradic stimulability of the muscles 
gradually passes away, but voluntary motion returns before the faradic 
current regains its control. Very frequently the paralyzed muscles will 
twitch or even act in vigorous spasm as regeneration in the nerve re- 
stores its irritability. Those cases which last a month or two, or more, 
usually leave traces for the rest of life. They may be so slight as to 
require careful scrutiny, or marked weakness may persist. Very excep- 
tionally the palsy is permanent. 

9 10 11 




( \ ( 




Fig. 49. — Same case six months later. 9 shows late contracture on the paretic side -while the face 
is at rest; 10, contracture in the lower half of the face increased by gently closing the eyes, and at the 
same time shows weakness about left eye; 11, contracture increased by raising brows, showing over- 
action of zygomatici and weakness of frontalis on left side. 

As the face recovers, in every instance the paretic side is likely to 
overact for all moderate voluntary bilateral movements. It would seem 
that the neuritis had left a certain nuclear irritability, so that a central 
influence, acting equally on both sides, produces a greater effect on the for- 
merly paralytic muscles. This secondary overaction is most pronounced 
in the lower half of the face, and often leads the patient to suppose that 
the sound side is becoming paretic. "When once strongly developed it 
practically remains for the rest of life, though slight degrees of it may 
pass away. While, therefore, the paralysis usually gets well, the sequel 
often remains and is irremediable, but is not of great amount or serious 
import. Indeed, many people who have never been affected show almost 
as much asymmetry of facial muscular action. Some cases present sev- 
eral attacks of facial palsy. Bernhardt 1 asserts that recurrence takes 
place in 70 fa of all cases and in men more commonly than in women. 
Second attacks are frequently associated with middle ear inflammation, 
syphilis, or diabetes. In the authors' experience second attacks are 
decidedly uncommon. Rossolimo 2 reports a recurring case associated 
Avith migrainous attacks. 

Diagnosis. — The diagnosis of a facial palsy, if at all marked, is 
made at a glance in the early stage. Later on the secondary overaction 
may momentarily mislead, but its nature should be easily deciphered. 
In slight volitional movements the overacting and consequently for- 
merly paralyzed side of the face responds in an exaggerated manner; 

1 "Neurol. Centralblatt. , " 1899. 

2 "Neurol. Centralbl.," Aug., 1901. 



130 DISEASES OF THE CRANIAL NERVES. 

but if the muscular effort be forced, as in vigorously screwing up the 
eyes and in laughing, the paresis will be manifest in the lessened action 
of the orbicularis palpebrse, though at the same time the zygomatici on 
the same side may be strongly overacting and exaggerating the naso- 
labial furrow. In the same way a strong attempt to uncover the teeth 
will show a weakness on the affected side. The distinction between a 
cerebral and a peripheral palsy will be made clear in the consideration 
of lesions within the skull. It suffices here to say that disease of 
the cortex and in the brain above the nuclei, as in ordinary hemiplegia, 
produces no muscular atrophy, no reaction of degeneration in the muscle ? 
and, with practical uniformity, never involves the brow and is most 
marked in the lower portion of the face. The tongue also is affected, as 
a rule. Lesions at the nucleus and in the pons almost invariably impli- 
cate other cranial nerves. Lesions at the base, as in meningitis, affect 
other cranial nerves usually, and always, when the face is paralyzed, pro- 
duce deafness from injury of the more vulnerable auditory nerve, the 
parallel course of which with the facial has been pointed out. 

The question as to the location and extent of the lesion in the usual 
peripheral palsy is an interesting one, and can be answered with some 
degree of precision. Referring to the diagram, page 124, it is evident 
that the neuritis, unless confined to a very short distance a"bove the stylo- 
mastoid foramen, will (1) involve the chorda and (2) produce loss of 
taste on the same side of the tongue, with diminished salivation. A little 
higher (3) the tympanic tensor nerve is cut off and the auditory symp- 
toms of hyperacousis for low tones, with blunting of hearing for notes 
of high pitch, will be added. At the internal (4) meatus the auditory 
nerve will also suffer and the chorda may escape. 

Prognosis. — The prognosis, while very good for practical recovery 
in all cases of facial neuritis, should always be guarded and guided by 
an electrical examination, which, after the second week, often furnishes 
information of a precise nature. Simple slight cases present no diminu- 
tion in faradic response or change in galvanic excitability. They may 
be expected to recover within a month. If galvanism and faradism of 
the nerve give diminished responses and galvanism of the muscles shows 
increased influence, with A. C. C. equal to or greater than C. C. C, the 
case will probably last two or three months. Finally, if the reaction of 
degeneration be complete, no responses in the nerve to either current ; 
the muscles refusing to act to faradism and showing overexcitability to 
galvanism with the anode overpassing the cathode, a year to eighteen 
months must be allowed. In this last group of cases marked and per- 
sistent overaction may and should be foretold. Bordier and Fraenkel * 
insist that the outward and upward deviation of the eye when the patient 
tries to close the lids is proportionate to the severity of the nerve injury, 
and recovers in an equal ratio. 

Traumata of the trunk of the nerve at its bony exit, even severing it, 
are not necessarily of grave outlook, as union and regeneration may follow. 
Middle-ear diseases and cranial fractures are likely to heal and the asso- 
ciated palsy to pass away. Naturally, the prognosis must be more 
1 "Sem. Med.," Sept., 1897. 



DISEASES OF THE FACIAL NERVE. 131 

guarded in these conditions, and is based largely upon the possibility of 
their recovery. 

Treatment. — The tendency to recovery being pronounced, can we 
shorten the duration of the disability ? It seems probable. If the case 
is seen early, a blister or leech on the mastoid may reduce the congestion 
in the facial canal. Hot applications to this region may be tried. If 
not thoroughly and persistently used, they are worse than useless and 
later on quite valueless. When the case is developed we recognize that 
the lesion of the trunk shuts off trophic and motor control. The indi- 
cation is to maintain the muscles in as perfect a condition as possible 
until the way for nuclear and cortical influence is reopened. Further, we 
should strive to keep the muscles as responsive as possible to the slight 
fraction of motor control that remains, or, if none is present, to the weak 
and inefficient impulses that will first reach them. To this end there 
are three things to do : (1) Keep the face in place by having the patient 
constantly push the cheek and mouth to their proper positions, from 
which every smile and word cause them to be dragged by the sound 
muscles. In the same way have the eyelids rubbed over the eyeball 
frequently, and at night a compress should be worn to keep them closed. 
This has the additional advantage of diminishing and often of prevent- 
ing conjunctivitis. A weakened muscle stretched by its sound antag- 
onists is not only placed at a mechanical disadvantage, but actually in- 
jured in its nutrition. (2) By means of massage and hot douches 
accelerate and improve circulation, and thereby the nutrition of the 
affected muscles. (3) By electrical stimulation of the muscles, com- 
menced from the first day, keep up their responsiveness. For this 
purpose a galvanic current only is needed. Faradism to contract the 
muscles, or the faradic brush, are needless and painful. Ordinarily the 
best plan is to use the anode at the motor points on the side of the face 
and to daily systematically cause the muscles to gently contract six 
to ten times by anodal closures. This pole is the least painful and the 
most active in the presence of degeneration. 

Traumatic cases are to be treated on surgical lines. If the nerve- 
trunk is divided, an attempt should be made to suture it. Breauvoine, 1 
in the manner advocated by Fanre and Furet, reports a fair success fol- 
lowing the establishment of an anastomosis between a diseased facial 
and the spinal accessory. This method is only applicable to those cases 
in which the nerve has no other possibility of regeneration. Anasto- 
mosis with the hypoglossal promises even better results. 2 Tympanic, 
mastoid, and pharyngeal trouble will require topical measures. When 
the neuritis is a part of general multiple neuritis, attention is directed to 
the toxic cause. Guided by the rheumatic idea, such remedies as the 
salicylates have been recommended and may be tried if the observer can 
convince himself that such a blood-state exists. Anemia and diminished 
physical forces from any general cause are not to be neglected. Strychnin 
may be of some service, acting as a nuclear stimulant and general tonic. 

Nuclear palsy of the seventh nerve manifests itself by the 

1 "Travaux de Neurologie Chirurgicale, " Jan., 1901. 

2 Ballance and Stewart, "Br. Med. Jour.," May 2, 1903; Taylor and Clark, 
"Med. Rec.," Feb. 27, 1901. 



132 DISEASES OF THE CRANIAL NERVES. 

same peripheral motor distribution as that found in diseases of the 
trunk, but lacks the gustatory , salivary, and sensory disturbances. The 
muscles degenerate in the same way and show the same electrical condi- 
tions. Almost invariably other adjacent cranial nuclei are implicated. 
This gives rise to a symptom group that easily differentiates the nuclear 
palsy from the peripheral form. In bulbar palsy the facial nucleus is 
generally invaded, and it may be affected in polio-encephalitis superior. 
The nuclear lesion usually produces bilateral symptoms. The pyramidal 
tracts are also commonly affected, and symptoms in the trunk, and espe- 
cially in the extremities, are present. 

An alternating palsy of the face on one side and of the limbs on the 
other is due to a low pontine lesion (see Fig. 44) affecting the facial 
fibers after their crossing and the pyramidal tract above its medullary 
decussation. 

Supranuclear facial palsy results from any lesion destroying the 
cortical facial centers or interrupting the communication of these centers 
with the facial nucleus. Ordinary capsular hemorrhage is, therefore, a 
frequent cause of facial palsy, but almost invariably at the same time 
causes hemiplegia. In these supranuclear palsies, as has already been 
indicated, the upper portion of the face partially or entirely escapes. 
Particularly is this true of the orbicularis palpebrarum, which acts volun- 
tarily. The slight weakness that is present is often shown by a partial 
ptosis completely at variance with the constantly open eye of the peripheral 
palsy, but the eye on the affected side usually can not be closed as vigor- 
ously as the other. All expressional bilateral movements in the lower 
face may be fairly retained, while voluntary control is practically lost. 
In the peripheral form the loss is equal in both varieties of action. 

In supranuclear palsy the muscles respond actively and normally to 
electricity, and their trophic condition is not impaired. In other words, 
the lower neuron is not involved. The reflexes are present for the same 
reason, and there are no auditory, secretory, or gustatory symptoms. A 
lesion that involves the optic thalamus may, according to Bechterew, 
cause loss of emotional expression on the opposite side. A lateral loss 
of expressional movements, with the retention of voluntary motion, 
therefore, points to the optic thalamus, which contains the centers for 
emotional expression. This loss has been found associated with corre- 
sponding bilateral hemianopsia resulting from the same lesion. 



CHAPTER VII. 

DISEASES OF THE EIGHTH CRANIAL NERVE. 

Anatomical Considerations.- — The eighth cranial nerve is purely 
sensory. It is made up of two portions : the cochlear branch, which 
alone conducts sound impressions, and the vestibular branch, which con- 
ducts space sensations from the semicircular canals. An accessory and, 
so to speak, adventitious portion is the intermediate nerve of Wrisberg, 
which is vasomotor and secretory in function. It passes to the facial 



DISEASES OF THE EIGHTH CRANIAL NERVE. 



133 



nerve and finally controls salivation. In consistence the auditory stem 
is much less firm than the facial. It follows that basilar lesions which 
affect the seventh almost necessarily involve the softer auditory, which 
lies beside it. But, on the other hand, a lesion that injures the auditory 
may not affect the more resisting facial or portio dura. 

At the apparent origin of the auditory trunk the internal vestibular 
portion, the one related to equilibration, passes backward and inward 
between the restiform body of the medulla and the ascending root of the 
trifacial nerve, to terminate in two groups of large cells. The outer 
cochlear portion, the true auditory root, separates from the vestibular 
root near the apparent origin, and, passing outward around the restiform 
body, turns inward on the floor of the fourth ventricle as the stria? acus- 
ticse, which dip down in the middle line to the nuclear cells of Clarke. 
At the point where these branches 
diverge the cochlear root presents 
a group of cells, for the vasomotor 
root of Wrisberg, analogous to a 
posterior root ganglion. Another 
group of cells, the acoustic tuber- 
cle, often of large size in animals, 
is placed just outside the restiform 
body, and is considered a pure 
auditory nucleus. The higher 
relations of the auditory nuclei 
are not clearly known, nor the 
exact course of the radiations to 
the cortex. There is every reason 
to believe that the vestibular nu- 
clei are in relation with the cere- 
bellum and with the cerebrum. 
The cochlear nuclei are connected 
with the temporosphenoidal cor- 
tex by fibers which pass through 
the posterior third of the sensory 
division of the internal capsule. 

Each ear is represented on both sides of the brain, but also principally 
upon the opposite side. The auditory center for speech, however, in right- 
handed individuals is practically confined to the left temporal lobe, the 
destruction of which produces word-deafness, or a loss of spoken-word 
memories. At its peripheral termination the auditory nerve enters the 
cribriform opening in the internal meatus. The auditory portion is dis- 
tributed to the cochlea and the organ of Corti. The labyrinthian portion 
is distributed to the vestibule and ampulla? of the semicircular canals. 

Irritation of the auditory portion of the eighth nerve is 
marked by auditory hyperesthesia, by increased acuteness of hearing (hyper- 
aeousis), and by tinnitus. It must be understood that continued irrita- 
tion of the auditory apparatus may result in diminished or lost function, 
just as overstimulation of any tissue or organ finally produces weakness 
and involution. It follows that tinnitus, for example, is often found with 




Fig. 50. — Diagram of a section showing the ori- 
gin of theeighth cranial nerve. V, Vestibular por- 
tion ; C, cochlear portion ; W, accessory of Wris- 
berg; A, accessory nucleus ; T, acoustic tubercle; 
E, restiform body; NC, nucleus of Clarke (after 
Brissaud). 



134 DISEASES OF THE CRANIAL NERVES. 

defective hearing. Hyperesthesia is frequently present in excitable and 
nervous persons. Migraine and all forms of pain often render the 
sufferer more sensitive to sudden noises, especially of high pitch, but 
actual hyperacousis is rare. In meningitis, acute mania, and under the 
influence of some stimulant drugs, such as alcohol, opium, anesthetics, 
Indian hemp, and catfein, the special sense of hearing is at times actually 
exalted. It is also conceivable that an irritant lesion of the auditory 
cortical centers might give rise to hyperacousis, and perhaps this is also 
the explanation of some hallucinations of hearing and sometimes of the 
rare auditory aurae of epilepsy. The increased acuteness of hearing for 
low tones in facial palsy has already been described. 

Irritation or disease of any part of the auditory mechanism is likely 
to produce a tinnitus which may vary widely with the same and with 
different cases. It may resemble hissing, roaring, buzzing, singing, tick- 
ing, throbbing, the sound of bells, and every conceivable monotonous 
noise. Cerumen or foreign bodies in the external meatus, inflammation 
of the middle eai, Eustachian occlusion, the throbbing of the carotid in 
its canal in the petron, rhythmical clonic spasm of the palate and orifice 
of the Eustachian tube in hysterics, meningeal irritation of the auditory 
nerve-trunk, perforations of the drum-head, sclerosis of the internal ear, 
and many other conditions may be symptomized by a tinnitus aurium. 
A tinnitus is present in some cases where aurists are unable to detect any 
peripheral cause, and persists practically unchanged throughout life. 
As a rule, a continuous tinnitus interferes with hearing, which is thereby 
diminished. Fortunately, it is frequently unilateral. Certain drugs, 
as quinin and the salicylates, cause tinnitus, and quinin in large and 
repeated doses has caused permanent deafness. A careful aural exami- 
nation is needed in every case of tinnitus, and the reader is referred to the 
special works on ear diseases. The treatment is that of the inciting 
condition. 

Paralysis of the auditory nerve and unilateral deafness may fol- 
low a cortical lesion involving the temporal lobe. Memories of heard 
speech seem to be stored \p in the first left temporal convolution. A 
destructive lesion here is followed by icord-deafness, and the patient no 
longer understands what is said, though he clearly hears the tones of the 
voice and all sounds. A bilateral lesion of the temporal cortex causes 
complete deafness. Lesions in the sensory portion of the capsule may 
cause a unilateral deafness on the same side with the accompanying 
hemianesthesia. A unilateral loss or diminution of hearing in the 
hemianesthesia of hysteria is not uncommon. It may come on suddenly 
and disappear in the same maimer. The presumption is that the cortex 
is functionally at fault. Complete — that is, bilateral — hysterical deaf- 
ness is seldom encountered. Nuclear disease of the eighth nerve is 
practically unknown, though tumors of the restiform body x and the 
medulla may involve the cochlear root. 

According to Virchow, the auditory trunk, most frequently of all 

the cranial roots, is the seat of new growths. Tumors at this point 

give rise to the general symptoms of brain-tumors, but are capable of 

definite diagnosis in at least some instances. According to Fraenkel and 

1 Brissaud, ' ' Lemons sur les Maladies Nerveuses, ' ' Paris, 1895. 



DISEASES OF THE EIGHTH CRANIAL NERVE. 135 

Hunt, 1 who have collected nine cases, the symptoms may be arranged 
as follows: (1) General: Headache, vertigo, vomiting, optic neuritis, 
bradycardia. (2) Focal: Peduncular ataxia, cerebellar ataxia, latero- 
pulsion, hemi-asynergy, homo-contralateral and crossed paralyses of the 
extremities, paralysis of the basilar cranial nerves, especially the seventh, 
sixth, and fifth, dysarthria, dysphagia, nystagmus, paralysis of the conjoint 
movements of the eyes, inequality of the pupils, and attacks of Adam- 
Stokes syndrome. (3) Special : Serious impairment of the function of the 
auditory nerve, of long standing and gradual onset. Gouty deposits and 
hemorrhage in the substance of the root have been found. It very fre- 
quently is involved in syphilitic meningitis. In purulent meningitis 
infection may travel along its sheath into the inner ear and produce 
deafness that is usually permanent. After exposure to cold the eighth 
nerve is sometimes subject to a neuritis similar to that so common in the 
facial, which may or may not be associated in the process. The condi- 
tion is marked by diminished or complete loss of hearing, but is of 
favorable prognosis. Artisans who work constantly amid loud noises — as 
boilermakers, tinsmiths, and other metal workers, engine-drivers and fire- 
men on railroads — often present a partial loss of hearing that may pro- 
gressively increase. They sometimes hear better in the accustomed tur- 
moil than in quiet places, and this is also true, but much less commonly, 
of ordinary deafness. The auditory nerve may be injured within the 
petron by the extension of inflammation from the mastoid, tympanum, or 
pharynx, and by basilar fractures. 

Diagnosis. — The first thing to be settled in a case of deafness is the 
integrity of the nerve. If the nerve is at fault, the condition is called 
nervous or nerve deafness. When there are no basilar symptoms, in- 
volvement of other cranial nerves, bulbar or cerebral indications, and 
when sounds of high and low pitch are not heard through the air or by 
bone-conduction, we may safely locate the disease in the nerve. Rhine's 
test (see p. 65) enables us, when the hearing is reduced, to fairly deter- 
mine whether the difficulty is in the conducting apparatus or in the nerve. 
A great reduction of hearing, in which air-conduction remains better 
than bone-conduction, but in which both are deficient, points to nervous 
deafness. Lesions within the brain-stem and in the temporal lobe must 
be determined by the association of symptoms peculiar to these localities. 
• Treatment. — In the treatment of nervous deafness we have first to 
investigate the aural apparatus and remove, if possible, any diseased con- 
ditions that may be present, All acute inflammatory trouble must 
subside before active measures are instituted. The use, then, of strych- 
nin, preferably hypodermatically, in much the same way as for optic 
atrophy, can be recommended. Electricity has small claims to notice, 
though usually suggested. Unfortunately, very little improvement can 
be expected. Nerve deafness of sudden onset, whether due to syphilis, 
neuritis, congestion, or hemorrhage into the internal ear, is sometimes 
favorably modified by the use of pilocarpin in full doses twice daily for 
a week or two. 2 Free action on the skin is to be produced. In these 
cases quinin and the salicylates are contraindicated, though sometimes 
of value in the chronic forms. 
1 "Ann. of Surg.," Sept., 1904. 2 Dundas Grant, ' l Brit. Med. Jour.," Nov. 16, 1896. 



136 DISEASES OF THE CRANIAL NERVES. 

Disease of the Vestibular Portion of the Eighth Nerve. — Aural 

Vertigo, Meniere's Disease. — The function of the semicircular canals is 
to furnish information relative to position in space. This information, 
of course, is correlated with similar information derived through sight, 
touch, joint sensation, muscular sense, and perhaps even to a slight 
extent through hearing. The canals are the principal organs of special 
orientation. Placed in three different planes they act much like three 
small spirit levels. Any movement, either active or passive, of the 
endolymph and the otoliths against the sentient nerve-endings produces 
a stimulus which is transmitted to the brain by the vestibular branch 
of the eighth cranial nerve. The flow of endolymph may be occasioned 
by movements of the head, modifications of pressure within the laby- 
rinth, or decided changes of temperature causing thermal currents in 
this fluid. Certain toxic and autotoxic substances may also cause vertigo 
by upsetting these space organs or their nervous mechanism. It is 
only necessary to mention tobacco and alcohol. 

It has long been recognized that disturbance in the internal or middle 
ear, and even in the external meatus, may cause not only tinnitus, but 
vertigo. The sudden inflation of the drum through the Eustachian 
passage, the use of interrupted galvanic currents about the ear, and any 
instrumentation within the tympanum or the external meatus may 
produce giddiness. If destruction of the vestibular branch takes place, 
the vertigo ceases. In cases of aural vertigo external objects seem 
always to revolve to the right or to the left. In other instances the 
vertigo is subjective, and the patient feels as if revolved to the right or 
left or as if falling forward, backward, or downward. The intensity 
of the vertigo varies greatly. It may be quite insignificant or it may be 
so pronounced that the patient holds to any neighboring person or 
object, staggers, or is even forcibly projected in some given direction. 
The attacks are usually paroxysmal, with relative freedom in the inter- 
vals. In the form described by Meniere the victim is struck down as 
if shot, there may be unconsciousness for a few moments, and the 
patient is often pale and covered with perspiration. Nausea and vom- 
iting may occur. 

Attending aural vertigo there is an associated nystagmus which 
corresponds to the ear and even to the semicircular canal that is affected. 
This nystagmus consists of lateral, vertical, oblique or rotary rhythmical 
movements of both eyeballs made up of two phases: (a) a slow move- 
ment in one direction and (b) a quicker return. Voluntary deviation 
of the eyes in the direction of the quicker movement accentuates the 
nystagmus, and, per contra, deviation of the line of vision in the direc- 
tion of the slow movement diminishes the nystagmus. The variety of 
nystagmus is named according to the quick movement. Thus a right 
nystagmus is one that presents the quicker movement to the right. 

When aural vertigo is attended by its associated nystagmus the 
person so affected tends to move and even to fall in the direction of the 
slower nystagmic movement. At such times if he try with closed eyes 
to touch a given object with his finger he points to one side of it, and 
always to the side corresponding to the direction of the slow movement. 



DISEASES OF THE EIGHTH CRANIAL NERVE. 137. 

The great majority of cases of aural vertigo occur after thirty years 
of age. In childhood they are extremely infrequent and rapidly increase 
after middle life, men being affected twice as frequently as women. 
Gout, rheumatism, and the sclerotic changes of old age are frequently 
causal. These may act directly upon the labyrinth or indirectly through 
the blood-supply and the pressure of the endolymph. A vasomotor 
element is given considerable importance by some. The irritation of the 
vestibular filaments is usually associated with auditory phenomena, 
so that tinnitus and defective hearing are almost invariably present. 
The close anatomical relations of the two portions of the eighth nerve 
explain this. In some cases the labyrinth has been found the seat of 
hemorrhage or local disease. Sometimes its epithelial structure is 
degenerated. Usually disease of the middle and external ear is wanting 
in the severest cases, while decreased hearing and tinnitus point strongly 
to involvement of the nerve itself. Some of the cases of the Meniere 
type show a progressive tendency, with failing hearing, first in one, 
then in the other, ear. Complete physical disability may ensue, due to 
the vertigo and attacks of falling. In some instances the disease re- 
mains at a standstill for years, and may even recede and hearing be 
restored. Again, when hearing is lost the vertiginous attacks may 
cease. Milder varieties run various courses, depending upon their 
causation and other conditions. 

Diagnosis of an aural vertigo depends in practice partly upon the 
association of auditory symptoms. Tinnitus or defective hearing, or 
both, are ordinarily present. The defect in hearing, as tested by bone- 
conduction, is sometimes unexpectedly great, the ticking of a watch 
when placed on the mastoid being inaudible. If the vertigo is produced 
or increased by changing the air-pressure in the tympanum, as by firmly 
pressing the tragus into the meatus or by Politzerization, the signifi- 
cance of that fact is great. Frequently the attack of vertigo is associated 
with an intensification of the tinnitus, or there are subjective sounds 
of a violent character, described as "pistol shots," "something breaking 
in the head," etc. Sometimes a quick movement of the head, as in 
turning over in bed or in a given direction, produces it. This apparently 
has relation to a particular semicircular canal, which is mainly or alone 
affected. A further characteristic of aural vertigo is the fact that the 
subjective or objective gyrations are uniform in the given case, or the 
stagger or falling is always in the same direction. In epilepsy we not 
infrequently encounter an indescribable vertiginous aura, but never 
the formulated vertigo of aural disease. The epileptic attack is usually 
followed by mental hebetude, which is lacking in aural attacks, where 
the vertigo may be maintained for a long time, giving rise to distressed 
feelings, vomiting, and collapse. The sensorium is always clear in aural 
vertigo, excepting the initial momentary unconsciousness of the severest 
form, or in the delirium that a continuation of the extremest variety 
may produce in very rare instances. The vomiting usually gives rise 
to the idea of "biliousness," and frequently a brisk cathartic, relieving 
all the symptoms of vertigo, is supposed to confirm the idea of intestinal 
or hepatic derangement, its influence on cerebral circulation being over- 



138 DISEASES OF THE CRANIAL NERVES. 

looked. Again, the sudden onset of the attacks in the Meneire form 
suggests cerebral disease or cardiac attacks, to which mistake the age of 
the patient and his arterial degeneracy often conduce. The repetition 
of the aural attack during periods of rest, and even during sleep, with 
absence of cardiac and cerebral symptoms in the meanwhile, should 
correct a misconception of this character. 

In recent years a number of valuable labyrinth tests have been 
developed based upon the association of vertigo and nystagmus. 
Ewald found that he could produce in animals a definite rotation of the 
head with a definite nystagmus by making pressure on a given semi- 
circular canal, and opposite movements by reduction of endolymph 
pressure. In man when there is a fistulous opening into the internal 
ear, similar pressure conditions induced by hand-bulb apparatus may 
cause identical results if the vestibular nerve is intact. Following the 
turning methods of Barany, if a normal person with closed or covered 
eyes, the head erect, be turned to the right about his vertical axis ten 
times in twenty seconds, upon stopping the rotation a nystagmus will 
be observed in both eyes. During the rotation the nystagmus is to the 
right, but upon arresting the rotation it becomes a left nystagmus. 
Mechanically, in turning a patient to the right, as in a revolving chair, 
the endolymph in the horizontal canals lags behind and this gives a 
definite stimulus associated with spacial experiences aroused by such 
movements and a right nystagmus. Upon suddenly arresting the rotary 
movement the endolymph surges to the opposite end of the canal and 
an opposite nystagmus is produced, which lasts twenty to forty seconds. 
As it is difficult to observe the nystagmus during rotation, the secondary 
nystagmus is the one commonly noted in these tests, and is the one 
always understood unless otherwise specified. Apparently the nystagmic 
movements are ocular attempts to re-establish spacial orientation. 

In these turning tests vertigo is also experienced. When the rota- 
tion is stopped the patient still feels as if being turned to the right, and 
with closed eyes points to the right of any object and tends to fall to 
the right, that is, in the direction of the slow nystagmic movement. 
Reversal of the rotation reverses the nystagmus in every particular, 
unless there be one-sided labyrinthine disease, when the corresponding 
nystagmus will be proportionately reduced. With the head placed in 
various positions, so as to bring the other canals into the plane of rota- 
tion, similar vertigos and nystagmic movements are induced. If, how- 
ever, the semicircular canals or the vestibular nerve be diseased the 
nystagmus is much reduced, and upon the destruction of the canals or 
division of the vestibular nerve it does not occur at all. 

As both ears and both eyes are in mutual and bilateral relation in 
the function of physical orientation, these turning tests do not enable 
one to test each ear separately, but are highly valuable in conditions 
such as otosclerosis affecting the internal mechanism or the nerve 
supply of both ears. 

Thermic tests have the advantage that they can be applied to each 
ear alone, and by changing the position of the head any canal may 
be examined singly. Water 20° F. above or below the body temper- 



DISEASES OF THE EIGHTH CRANIAL NERVE. 139 

ature is slowly injected into the meatus, freed of any local obstruc- 
tion. The warm water sets up currents in the endolymph which, of 
course, are reversed by cold water. The effect of the cold water (78° F.) 
in one ear produces nystagmus to the opposite side, while icarm water 
(118° F.) causes nystagmus to the same side. Vertigo follows the nys- 
tagmus in a few moments. The cold water produces its nystagmic ef- 
fect in about thirty seconds, and the ocular movements persist much 
longer than after the turning test, owing to the prolonged thermic 
effect on the bones and soft parts. Such effect must be allowed to pass 
before the test is repeated on the same or opposite side, or it can be 
terminated by an aural douche of water at body temperature. In order 
to get the best results from the thermic test the patient, if sitting up, 
should bend the head well backward at an angle of about 60 degrees. The 
test is measured by the promptness with which the nystagmic reaction 
is produced and its duration. Any lesion of the vestibular tract, from 
nerve centers to end organs in the semicircular canal, causing reduction 
of functional activity, may give a corresponding reduction of activity 
to this test, and, per contra, any such lesion may be attended by a con- 
stant or intermittent nystagmus. According to Neumann it is possible 
to differentiate between the nystagmus of cerebellar disease and that of 
the labyrinth, in that the cold-water test causes a nystagmus to the 
same side in the cerebellar lesion. For more elaborate descriptions of 
labyrinthine tests and diseases the reader is referred to special works 
on ear disease 

The labyrinthine variety may be readily confused with ocular vertigo 
in some instances, as it occasionally gives rise to persistent nystagmus, 
and even has produced diplopia. The patients sometimes describe oscil- 
lating movements in viewed objects, rapid in one direction with slow re- 
turn, similar to the nystagmic movements of the eyeballs. The mutual 
dependence of space sensations and ocular impressions only needs to be 
mentioned to explain the secondary ocular movements. Ocular vertigo 
ceases the moment the eyes are closed, but this has no effect on the aural 
form. 

Vertigo is associated with numerous abdominal disturbances, par- 
ticularly those of the stomach, liver, and small intestine. These forms 
of vertigo are usually attended by indigestion or other symptoms of a 
local character, and the vertigo commonly lacks the distinctive gyratory 
feature of ear trouble. In some cases of aural vertigo, however, the 
patients complain merely of ' 'dizziness," "giddiness," or "swimming" 
sensations. If the vestibule alone is involved, without any implication 
of the cochlea, as is conceivable, all auditional symptoms default. In 
such cases the diagnosis must largely depend on the exclusion of other 
sources of vertigo. 

Treatment. — If aural vertigo is recognized as an irritation symptom 
its rational treatment will depend on appreciating and, if possible, re- 
moving the basic disease. Cases may be relieved or even cured by 
Politzer's inflation, by the removal of cerumen, or by the correction 
of a pharyngeal catarrh. In others the sclerotic changes in the labyrinth 
are irremediable and treatment is directed to reducing the irritability 



140 DISEASES OF THE CR AXIAL XERVES. 

by bromids. Charcot strongly recommended in the Meniere type the 
use of quinin in large doses, but others have not had his success with 
that drug, and it should not be used in acute cases. He even advocated 
the destruction of the inner ear, producing loss of hearing, or, in other 
words, a removal of all irritability and the cessation of the vertigo at 
once, in the same way that sometimes occurs naturally. This has been 
practically applied by Milligan 1 with favorable results in three cases. 
Removal of the malleus and incus and mobilization of the stapes have 
given relief in many instances and may be advised with propriety, 
especially if the hearing is greatly impaired. Intracranial division of the 
auditory nerve has been done (Krause, Frazier), and in suitable cases 
of great severity should be recommended. When the vestibular appara- 
tus is destroyed by surgery or disease the other avenues of spacial per- 
ceptions seem to answer every purpose. Gout and arteriosclerosis, 
middle-ear disease, and lesions of the auditory stem must be treated 
in their own several ways. Electricity is of questionable value, though 
it is asserted by some that the positive pole over the tragus and the 
negative on the back of the neck, with a current of three or four milliam- 
peres gradually increased from zero, continued for five minutes and then 
decreased, has a quieting influence. All interruptions should be avoided. 
Cases of acute onset are sometimes benefited by pilocarpin, as in ner- 
vous deafness, with which they are usually combined. 



CHAPTER VIII. 

DISEASES OF THE GLOSSOPHARYNGEAL, VAGUS, AND 
ACCESSORY NERVES. 

Anatomical Considerations. — The glossopharyngeal and pneumo- 
gastric nerves and the bulbar portion of the spinal accessory should be 
considered as one mechanism. Their nuclei in the medulla are practi- 
cally inseparable, and they continuously furnish sensation and motion to 
the gastro-intestinal tract from the pharynx to the duodenum. In addi- 
tion they supply motor filaments, which all come from the accessory 
portion, to the lungs, larynx, and heart. They are visceral nerves. It 
is to be kept clearly in mind that the spinal portion of the accessory is 
a pure motor nerve to the skeletal muscles of the neck, and is only 
locally associated with the pneumogastric. The interrelations of the 
glossopharyngeal-vagus-accessory group are so complex, their distribu- 
tion so wide-spread, and their indirect disturbances so vague that they 
furnish many perplexities. A short outline of the glossopharyngeal is 
first given, and then the vagus and true accessory are discussed together. 



DISEASES OF THE GLOSSOPHARYNGEAL NERVE. 

The ninth cranial nerve is still a source of anatomical contention 

and physiological doubt. In consequence its diseased conditions are 

uncertain and obscure. Practically, in man, it is never alone diseased. 

If its relations to other cranial nerves are considered, this fact is readily 

1 "Brit. Med. Jour.," Nov. 5, 1904. 



DISEASES OF THE VAGUS GROUP. 141 

understood. Through Jacobsoir's nerve it forms, with the sympathetic, 
the tympanic plexus, whence a branch connects it through the Vidian 
with the facial nerve, and another branch through the small superficial 
petrosal connects it with the otic ganglion. It is connected with the pneu- 
mogastric at the petrous ganglion of that nerve, and also in the pharyn- 
geal plexus. Its nuclei are intimately associated with those of the vagus 
and accessory nerves. It probably subserves sensation in the upper 
part of the pharynx and in the tympanum, and nausea is associated 
with its disturbance. Probably through its distribution to the root of 
the tongue it peripherally carries the fibers of the special sense of taste 
for that area, but these are not embraced in its root. They reach the 
brain by a circuitous route, probably entering the petrous ganglion of 
the glossopharyngeal nerve from the middle branch of the fifth through 
the tympanic plexus and otic ganglion. It seems to have some motor 
control of the upper portion of the pharynx, and, perhaps, of the 
palate. 

Intracranial disease and cranial fractures may implicate the glosso- 
pharyngeal, causing weakness and some insensitiveness in the upper 
pharynx and in the palate. Its nuclei in the medulla usually suffer in 
bulbar palsy, and thus are produced, at least in part, the pharyngeal 
symptoms of that disease. 

DISEASES OF THE VAGUS AND BULBAR PORTIONS OF 
THE ACCESSORY, 

Pharyngeal Branches. — The pharyngeal branches of the pneumo- 
gastric follow below the glossopharyngeal, and with it form the pharyngeal 
plexus, supplying motion and sensation to the uppermost portion of the 
intestinal tube. These, branches are paralyzed by nuclear disease 
and in diphtheric palsy, but seldom otherwise. Bulbar involvement 
is invariably attended by symptoms in other cranial nerves. The 
pharynx is more or less insensitive and motionless. The pharvngeal 
reflex is lost. Food tends to accumulate and lodge in the gullet or 
overflows into the larynx, producing spasmodic cough and strangling. 
If the palate at the same time is weakened, food and fluids may be 
forced into the nasal passages and regurgitate through the nose. A 
pharyngeal spasm furnishes the condition commonly noted in hysteria 
as "globus/' or esophagismus, and is always functional. At times it 
may be mistaken for pharyngeal paralysis, or the difficulties in swallow- 
ing in the latter may be attributed to spasm. The use of a sound will 
at once clear the doubt. The decided pharyngeal grasp of health is in- 
creased in spasm and lost in paralysis. Moreover, spasm is temporary 
or recurrent, and paralysis is continuous. 

Laryngeal Branches. — The larynx is innervated by two branches 
of the pneumogastric : (1) The superior laryngeal governs the move- 
ments of the epiglottis and controls tension in the vocal cords through 
the cricothyroid, which is the only intrinsic laryngeal muscle supplied 
by this nerve. It also furnishes sensation to the larynx above the vocal 
cords. (2) The recurrent laryngeal, which turns about the aorta on the 
left side and the subclavian artery on the right side, supplies sensation 



142 



DISEASES OF THE CRANIAL NERVES. 



to the trachea and to the larynx below the vocal cords. It controls all 
the intrinsic laryngeal muscles except the cricothyroid. These muscles 
have three principal vocal actions : First, to draw the vocal cords tense ; 
second, to bring them close together ; third, to draw them apart. Though 
many laryngeal movements are highly complex, requiring the synergic 
action of several groups of muscles, it is well to remember that the 
chief tensors are the cricothyroids, the chief abductors are the posterior 
crico-arytenoids, the chief adductors are the lateral crico-arytenoids. In 
addition, the thyro-arytenoids, which in part form the vocal cords, serve 
to stiffen them and make their apposition uniform and effective. By 
some they are considered tensors and by others laxors of the cords, and 
probably serve both purposes. 

Laryngeal paralyses vary in degree and in distribution. They 
may be unilateral or bilateral, partial or complete. Further, the abduc- 
tors, the adductors, or the tensors of the cords may be alone or mainly 
involved. Abductor paralysis is, however, by far the most common, 1 
even when the lesion falls upon the recurrent. A full knowledge of the 
anatomy and mechanism of the larynx is required to understand this 
subject, and the use of the laryngoscope is requisite for exact diagnosis. 
The following table is given to show the common varieties of laryngeal 
paralysis, with diagrams of the corresponding mirror pictures, which 
should be compared with the normal outlines in phonation, respiration, 
and death. 

Laeyngeal Paealyses. 



Form of Paralysis. 


Muscles Involved. 


Causes. 


Symptoms. 


Bilateral adductor 


Both lateral crico- 


Anemia, physical 


Voice lost, but cough 


paralysis. 


arytenoids and 


weakness, hysteria. 


and laugh phonetic ; 


(Fig. 54.) 


the arytenoide- 




respiration and swal- 




us. 




lowing normal ; no 
pain. 


Unilateral adduc- 


One lateral crico- 


Toxemia, lead, diph- 


Diminished voice ; 


tor paralysis. 


arytenoid. 


theria, cerebral dis- 


hoarseness ; cough- 


(Fig. 55.) 




ease, small-pox, 


ing, laughing, and 






syphilis, phthisis. 


sneezing diminished ; 
difficulty in swallow- 
ing occasional. 


Bilateral abductor 


Both posterior 


Toxemia, hysteria 


Voice little affected for 


paralysis. 


crico-arytenoids. 


rarely, injury to both 


ordinary efforts ; re- 


(Fig. 56.) 




recurrent nerves, as 


spiration impeded ; 






by enlarged bron- 


extreme inspiratory 






chial glands ; dis- 


stridor, with free ex- 






eased thyroid, new 


piration. 






growths in the neck, 








etc. 




Unilateral abduc- 


One posterior 


Stretching or injury to 


Voice harsh, impure, 


tor paralysis. 


crico-arytenoid. 


one recurrent nerve, 


and hoarse ; some in- 


(Figs. 57 and 58.) 




as by aortic aneur- 
ysm, and the same 
causes as in the bi- 
lateral form, acting 


spiratory stridor. 






on one side only. 





iSemon, "Brit. Med. Jour.," Jan. 1, 1898. 



DISEASES OF THE VAGUS GROUP. 
Laryngeal Paralyses. — {Continued.) 



143 



Form of Paralysis. Muscles Involved. 


Causes. 


Symptoms. 


Bilateral paralysis Cricothyroids, 
of tensors. 


Colds; voice straining; 
diphtheria. 


Hoarseness ; inability 
to take high notes. 


Paralysis of the 

cords proper. 
(Figs. 59 and 60.) 


Thyro-arytenoids. 


Overexertion, hysteria. 


Loss of falsetto notes 
and uncertainty of 
voice-p roduction; 
usually attended by 
some adductor pare- 
sis, and frequently by 
loss of power of the 
arytenoideus. 






Fig. 51.— Normal phonation. 



Fig. 52. — Normal deep 
inspiration. 



Fig. 53. — Normal cadaveric 
position. 






Fig. 54. — Bilateral adduc- 
tor paralysis. Attempted pho- 
nation. 



Fig. 55.— Left adductor 
paralysis. Attempted pho- 
nation. 



Fig. 56 —Bilateral abductor 
paralysis. Deep inspiration. 





Fig. 57. — Left abductor paraly- 
sis. Deep inspiration. Affectedcord 
in cadaveric position. 



Fig. 58.— Left abductor paraly- 
sis. Phonation. Affected cord in 
cadaveric position. Right cord 
crossing median line. 





Fig. 59.— Bilateral thyro-arytenoid 
paralysis. 



Fig. 60.— Bilateral thyro-aryte- 
noid paralysis and paralysis of ary- 
tenoideus, giving an hour-glass open- 
ing. 



144 DISEASES OF THE CRANIAL NERVES. 

In complete bilateral paralysis of the larynx, such as results from 
injury to both recurrent nerves, the vocal cords occupy the cadaveric- 
position, and are motionless. There is no voice, and coughing and 
sneezing are impossible. Deep inspiration develops stridor. If the 
complete paralysis is unilateral, the motionless, paralyzed cord occupies 
the cadaveric position, while its fellow moves actively in phonation and 
respiration, even passing the middle line in adduction. The voice is 
low-pitched and hoarse, cough is absent, and stridor only appears on 
very deep inspiratory efforts. 

The treatment of laryngeal palsies depends on that of the causa- 
tive condition. Laryngeal palsies due to surgical injury of the nerve, 
as by the inclusion of the pneumogastric in ligation of the carotid, or 
its division in operations on the thyroid, have occurred. Here the 
immediate danger is to the heart. In the diphtheric forms and in other 
toxic varieties, the use of electricity is recommended. To be of any 
value it must be applied with the intralaryngeal electrode and requires 
special skill. The neuritic forms of laryngeal palsy are of fair prog- 
nosis, with or without treatment, if the patient survives the early effects 
of the toxemia. The nuclear varieties are practically irremediable. 

Anesthesia of the larynx is occasioned by interference with the 
superior laryngeal nerve, which supplies sensation above the vocal cords. 
It may be unilateral or double-sided. In hemianesthesia from cerebral 
lesions and hysteria it may be unilaterally present, with preserved re- 
flexes, which are lost in nuclear or trunkal disease of the pneumogastric. 
Hysterical adductor paralysis with aphonia commonly presents a loss of 
sensation at the laryngeal inlet. 

Laryngeal spasm is due to irritation of the recurrent laryngeal 
nerve or to reflex causes mainly arising in the pneumogastric periphery 
and acting through this branch. With the reflex action that protects the 
larynx from the entrance of foreign bodies we are familiar. This may 
be intensified by local irritation, as in catarrhal laryngitis, especially in 
children, giving rise to croupy cough and attacks of croup at night. 
The laryngismus stridulus of rickets, or tetany, or enlarged thymus, or 
in goitrous, pubescent girls, is due to adductor spasm. It may be de- 
pendent upon a long uvula, enlargement of the pharyngeal tonsil, or 
nasal conditions sufficient to provoke the reflex. Indigestion, especially 
in children, and more particularly in ill-nourished children, is a common 
source of reflex laryngeal spasm. It may, in adults, be the result of 
injuries to the nerve. It not uncommonly is the neurotic equivalent 
of asthma or migraine, with which it may alternate. The epileptic cry 
is due to a laryngeal and thoracic spasm. There is a variety that is 
sometimes called laryngeal epilepsy. It may be an element in hys- 
terical convulsions, or the only representative of such attacks. 

A partial laryngeal spasm in severe stammering sometimes induces an 
explosive utterance attended by evident respiratory difficulty. From 
overuse of the voice, especially by bad methods, a spasmodic neurosis 
of the larynx similar to a writer's cramp may be set up. Speech at first 
is fairly uttered, but the unbalanced and spasmodic action of the vocal 
apparatus promptly manifests itself by loss of modulation and by ex- 



DISEASES OF THE VAGUS GROUP. 145 

plosive enunciation. Laryngeal spasm is marked by a sudden onset and 
often comes on during sleep. There is every evidence of dyspnea, and 
the marked stridor, both on inspiration and expiration, serves to distin- 
guish it from abductor palsy of the larynx. The attack is very short, 
lasting but a few seconds at most. 

A number of spasmodic nervous coughs are described, such as the 
barking, explosive, incessant cough of hysteria, the metallic ovarian 
cough of young girls, and the barking coagh of pubescent and mastur- 
bating boys. In all of these conditions there is a strong neurosal ele- 
ment that must be given first importance in etiology and treatment. 

Pulmonary Branches. — The pulmonary branches of the pneumo- 
gastric with branches from the sympathetic ganglia accompany the 
bronchi into the lungs. It is probable that the vagus supplies motor 
filaments to the bronchial muscles of unstriped fiber. The nutrition of 
the lungs also seems to be under their control, though the vasomotor 
supply comes through the sympathetic. It has been noted in animals 
that death, after division of the vagus, is due to pneumonia. The prin- 
cipal pneumogastric pulmonary derangements are bronchial asthma and 
protracted hiccup, which in some rare cases are interchangeable. 

Bronchial or Spasmodic Asthma. — The early contention of 
Trousseau, Williams, and others, that there occurs a spasm of the bron- 
chioles in asthma, is confirmed by Bert and proven by Biermer. It is 
accompanied by turgescence of the mucosa and a characteristic exudate 
of mucin in the form of spirals, which often contain polygonal 
crystals, by Ley den supposed to be causal of the attack. There can be 
no doubt that this neurosis is common in some families by direct 
inheritance for generations. In rare cases in the same patient it has 
alternated with migraine or attacks of hiccup, and even with epilepsy. 
In other instances, again, in neurotic stock it has taken the place of 
graver neuroses and of the psychoses in members of the same or suc- 
ceeding generations. While it may originate apparently without any 
cause extraneous to the individual, in many cases every attack can be 
traced to certain irritant factors, such as the inhalation of dust, the 
pollen of certain plants, or a certain odor. It has been shown by Hack 
and confirmed by many others that nasal conditions may incite and 
prolong the attacks, which do not appear when the source of nasal reflex 
irritation is removed. In the same way intestinal and genital disturb- 
ances may, in individual cases, be the starting-point of the attacks. 
Spasmodic asthma is also associated with defective renal activity and 
the various acute and chronic uremias. Its relation to gout, rheuma- 
tism, and plumbism is not less clear. In every instance a potential 
state must be present, and these peripheral or endogenous excitements 
merely fire the train resulting in the nervous explosion of the asthmatic 
attack. 

Spasmodic asthma, except in the form of hay asthma, rarely appears 
before adult age. It is more frequent in men than in women, a fact 
that is to be explained by their greater exposure to the inclemencies of 
the weather. There is no doubt that laryngeal and bronchial irrita- 
tion from such cause may be provocative of the asthmatic attack. In 
10 



146 DISEASES OF THE CRANIAL NERVES. 

long-standing cases the secondary pulmonary emphysema and chronic 
bronchitis constantly keep the spasmodic features within striking distance. 
Symptoms. — Asthmatic attacks come on, as a rule, with considerable 
suddenness, and are marked by intervals of practically complete relief. 
Except in the hay-asthma varieties, the patient most frequently is awak- 
ened from sleep by distressed breathing that rapidly grows worse. Inspir- 
ation and expiration are both difficult, and expiration is greatly lengthened. 
As the dyspnea increases and persists the face is suffused and the lips be- 
come bluish. The patient is covered with perspiration and evidences his 
distress only too plainly by the laboring chest, the anxious and drawn face, 
and the noisy, blowing, wheezy respiration. The thorax is rounded, the 
diaphragm depressed, and its excursions diminished ; the muscles at the 
neck are in strong relief in the attempt to increase the respiratory action. 
The patient calls for air. He often props himself up in bed or on chairs 
and other objects to raise and fix the shoulders, thereby increasing the 
action of the adventitious respiratory muscles. At last, when he seems 
unable to endure longer, the spasmodic breathing lessens, relief is expe- 
rienced, and he may fall into the sound sleep of exhaustion, perhaps to 
be again awakened after a few hours by a repetition of the attack. The 
first attacks are usually mild, and only attain the indicated intensity after 
a number of asthmatic bouts. In the advanced and ancient cases a small 
degree of spasm may be continually present, manifesting itself upon 
the slightest exertion or exposure. During the attacks the physical 
signs are very slight. Roughened bronchial breathing and moist rales 
are noted. At first hard coughing brings up a little mucus, but toward 
the end of the attack a considerable quantity is frequently ejected with 
apparent ease and relief. 

Treatment. — In the management of asthma the neurotic condition 
should ever be kept in mind. General measures to build up the tone 
and stability of the nervous system are essential. Outdoor life and 
moderate exercises, hydrotherapy, tonics, correct habits, and hygienic 
measures are indicated. The inciting element must be most carefully 
and persistently sought. If this can be recognized early, its removal 
gives hope of complete immunity from the recurring attacks that in so 
many cases make life wretched. It is probable that every repetition of 
the asthmatic storm reduces the power of resistance and serves to estab- 
lish an increasing asthmatic habit. When this has been formed, and 
bronchitis with emphysema induced, a cure can not reasonably be 
expected. Regarding drugs, the iodid of potassium has a deserved repu- 
tation. It is particularly indicated in the chronic and uremic forms of 
asthma. Strychnin in large and increasing doses gives occasional aid. It 
may be given in doses increasing to -^ of a grain three times a day, if 
well tolerated. The correction of peripheral states in the nose, intes- 
tines, kidneys, genitals, etc., has been sufficiently urged. Climatic 
changes are of importance, but one can never predict the result of this 
measure. In every case it is experimental. One patient will have 
complete immunity in a locality that is unbearable to another apparently 
similar case. In hay asthma a patient may secure relief one year at 
some resort and the following season find his journey futile. 



DISEASES OF THE VAGUS GROUP. 147 

The attack can often be cut short by the use of any one of a number 
of sedatives. Inhalations of nitrite of amyl or chloroform may give 
almost instant relief. Fumigations with niter and stramonium or some 
similar solanaceous plant are much in favor. Cigarettes and pastilles of 
such materials are prepared by the trade. The smoke must be deeply 
and freely inhaled. A dose of spirit of chloroform or of sulphuric 
ether is often productive of temporary benefit. Inhalation of steam 
charged with camphor is a ready and sometimes efficient measure. 
This is furnished by dropping a dram of any camphor preparation 
into a pint of boiling water in a small pitcher, over which the patient 
holds his face. 

Hiccup is usually referred to the phrenic nerve, the diaphrag- 
matic action being considered its most important feature. It appears, 
however, to be a respiratory difficulty, and is undoubtedly associated 
with the respiratory centers. Not only does the diaphragm act spas- 
modically, but there is a general thoracic inspiratory movement and a 
laryngeal fixation or spasm, giving rise to the peculiar inspiratory sound 
with which all are familiar. In some cases there are protracted attacks 
of hiccup that are neurotic equivalents for asthma or other nervous 
disturbance. Such attacks may also occur independently. Injury to 
the phrenic or to the pneumogastric, or even to the superior laryngeal 
nerve, has occasioned it. In hysteria it is not a rare manifestation, and 
may last for weeks during the waking hours. It may be dependent 
upon distant reflex irritation in the intestine or genito-urinary tract, or 
upon affections of the larynx and pharynx. In all conditions when the 
respiratory centers are intoxicated or depressed, as in uremia, syncope, 
suffocation, after hemorrhage, in cholera, etc., hiccup may appear, and 
is of serious significance. 

The treatment of a protracted attack of hiccup is etiological. 
Some rebellious cases have been promptly terminated by inducing sneez- 
ing, which is the exact opposite of singultus. Sedatives of all sorts 
have at times seemed useful, and musk is especially recommended. 
Faradism to the phrenic nerve and diaphragm has served a good pur- 
pose. In the hysterical cases often nothing short of complete isolation 
and the most thorough management of the hysterical condition will 
avail. 

Cardiac Branches. — The cardiac plexus is made up of accelerator 
branches from the sympathetic, and of the superior and inferior cardiac 
branches of the vagus, respectively given off from its cervical and 
thoracic portions. The vagus filaments are known to inhibit the 
heart's action, and are supposed to subserve sensation, being afferent 
in this function. Whether or not they contain trophic fibers for the 
heart is still disputed. Affections of the cardiac branches of the 
pneumogastric, or neuroses acting through these branches, modify their 
inhibitory function, or give rise to cardiac sensations, or both. 

Tachycardia is undue rapidity of the heart's action. It may be 
temporary or permanent, and is due to the increased accelerator sympa- 
thetic influence or to decreased vagus inhibitory control, or to both act- 
ing together. Some individuals have naturally a quick heart. The term 



148 DISEASES OF THE CRANIAL NERVES. 

tachycardia is here limited to an acquired rapidity aside from that of 
exertion, that associated with elevation of body-heat, hemorrhage and 
weak heart, convalescence from acute illness, etc. It may be temporary 
or permanent, but usually occurs in attacks or paroxysms in which the 
patient feels distressed and anxious, often presents flushings and other 
vasomotor disturbance, and the pulse may be found beating at 120 or 
even attain a rate of 300 or more a minute. Of this the patient may 
be unconscious, in which respect it differs from palpitation, an essentially 
subjective sensation. The attack often terminates rather suddenly, and 
may be followed by free sweating, copious urination, or even by diarrhea. 
Nothnagel gives the following distinctions between accelerator irritation 
and vagus paralysis : Great increase in frequency of pulse, with weak 
heart-sounds and other disturbances in the pneumogastric area, as 
aphonia, hoarseness, gastralgia, or cardiac pain, refer to the vagus. 
Strong heart-sounds and impulse, full peripheral vessels, and vasomotor 
storms indicate accelerator disturbance. Whittaker 1 says the increase 
to 120 beats implies irritation of the sympathetic; from 120 to 180 
beats, paralysis of the vagus; above 180, the combined effect of both 
causes. 

Tachycardia may be due (1) to disease of the heart and blood- 
vessels, (2) to injury of the vagus trunk or nucleus, (3) to toxic causes, — 
alcohol, nicotin, coffee, and atropin, — (4) to a reflex from any viscus, 
especially those in the pneumogastric field, and (5) to many neuroses, as 
Graves's disease, hysteria, and neurasthenia. The prognosis and treat- 
ment necessarily depend on the causation. The purely neurotic forms 
are difficult to manage, though not of serious import so far as life is con- 
cerned. 

Cardiac palpitation is sometimes a purely nervous condition, a 
vagus neurosis. Hysterics and neurasthenics are often much troubled 
by this rapid heart-action, of which they are perfectly aware. It may 
come on independently of any assignable cause, as during moments of 
rest, or even during sleep, though here the influence of some dis- 
tressing dream can not be excluded. It lacks the anxiety and often 
associated heart-pain of tachycardia and angina pectoris, but is often 
attended by tinnitus, vertigo, and a feeling of faintness. All source 
of cardiac disturbance must be excluded before admitting this form of 
vagus disturbance. 

Unless it is merely symptomatic, the etiology is obscure and its treat- 
ment difficult. Sedatives and narcotics, with local applications of heat 
or cold over the precordium and the administration of diffusible stimu- 
lants, may be employed to arrest the attack. 

Bradycardia is the opposite of tachycardia. A slow pulse is 
apparently normal to many individuals and is not associated with any dis- 
tress or difficulty. Such instances, in which the heart-beats are twenty, 
thirty, or forty a minute, are on record. The term is here limited to an 
acquired slow beat that may be permanent, temporary, or paroxysmal. 
It is sometimes noted in cervical myelitis or injuries to the cord in this 

1 "Twentieth Century Practice," vol. iv. 



DISEASES OF THE VAGUS GEO UP. 149 

region. Cerebral conditions marked by pressure, as hemorrhage, hydro- 
cephalus, and tumor, reduce the pulse-rate, and it is often slow in meningitis. 
The actions of narcotics, biliary poisoning, and uremia only need to be 
mentioned. Many infective diseases, such as rheumatism, puerperal fever, 
typhoid, and diphtheria, may produce bradycardia of a persisting sort, or 
may be followed by it. They probably, at times, set up a vagus neuritis. 
Organic processes acting on the pneumogastric cardiac inhibitory center, or 
on its cardiac fibers, may retard the heart by the irritant stimulation of the 
inhibitory function. Disease of the heart-muscle itself, as in fatty heart 
and coronary sclerosis, may produce bradycardia, and seems to act by irri- 
tation of the terminal filaments of the vagus. The nuclear variety is 
often associated with arteriosclerotic changes in the medulla. 

Bradycardia is usually attended by syncopic disturbance, which has 
not rarely been mistaken for epilepsy. The paroxysmal form, as in the 
Stokes-Adams syndrome, is often marked by anxiety, unrest, and dis- 
tress in the precordial region. Cardiac angina and nausea, or vomiting, 
may ensue. Convulsions are sometimes noted. When the vagus trunk 
is affected, other motor symptoms may indicate it, such as aphonia, 
hoarseness, stridor, and choking. The diagnosis of bradycardia is not 
difficult, but the heart-beat should never be determined by the radial 
pulse. The treatment and prognosis depend on the causal condition. 

Angina pectoris is an affection of the vagus marked by paroxysms 
of agonizing pain in the region of the heart, which radiates usually to 
the left shoulder and arm, and is attended by a sensation of impending 
death. By some it is called true angina pectoris when dependent, as is 
usually the case, upon organic heart disease, in distinction from false or 
pseudo-angina, in which no anatomical changes are discoverable. There 
is a strong probability that the sympathetic fibers participate in the storm, 
but the essential element is the vagus neuralgia. The attacks are some- 
times induced by exertion or emotion, but may rouse the patient from a 
sound sleep. Rarely occurring in children, it is much more common in 
male adults and in the latter half of life, when the arterial changes and 
cardiac myopathies are commonly found. It may occur independently 
of such organic changes in neurotic individuals, and is encountered in 
hysteria, subsiding with that neurosis or suddenly ceasing upon the 
appearance of other hysterical manifestations. 

The pain varies in character and severity. Its usual radiation to 
the brachial plexus may be replaced by epigastric, ilioscrotal, vesical, 
and even sciatic pain, ordinarily on the left side. The feeling of im- 
pending death, however, is an essential symptom. The pulse may be 
unchanged even in the presence of the most excruciating pain and the 
most frightful anxiety, or, rarely, the heart may present tachycardia or 
bradycardia. The patient is often bathed in perspiration, and in rare 
cases other pneumogastric conditions, as asthma, laryngeal spasm, or 
esophagismus, may attend the anginal attack. The attack lasts from a 
few minutes to an hour, and usually subsides as suddenly as it com- 
menced. The patient feels considerably shaken up and rather languid 
for a time, but in the intervals of the attacks may be completely free 



150 DISEASES OF THE CRANIAL NERVES. 

from all distress aside from that attributable to organic cardiac effects 
and the apprehension of another attack. 

The prognosis depends on the condition of the heart. If it is not 
organically diseased, the angina does not end fatally, and even cases of 
organic heart disease seldom die in anginal attacks. The treatment 
of the attack is antispasmodic. Amyl nitrite and trinitrin hold the 
first place ; chloroform by inhalation, the application of heat or cold to 
the precordium, whisky, and other similar measures are of some value. 
In the intervals treatment is directed to the condition of the heart or to 
the neurosis, or to both. 

Gastric Branches. — The pneumogastric supplies motor branches 
to the stomach, but only in part innervates the muscular coat of that 
viscus. Certain gastric movements, such as sobbing and vomiting, un- 
doubtedly depend upon its motor filaments. Vomiting is reflexly pro- 
duced through its gastric sensory fibers, as well as directly by intra- 
cranial disease or irritation of its trunk. Vomiting due to intracranial 
disease, or that provoked by irritating the vagus trunk and sometimes 
that due to irritation of its stomach branches by organic disease, is 
peculiarly rapid, projectile, and, as a rule, unattended by nausea. The 
vagus probably conveys the sensations of hunger, at least they have been 
completely destroyed by bilateral lesions of these nerves. Ravenous 
appetite for food and the peculiar subjective gastric sensations of dys- 
pepsia, organic disease of the stomach, and some neurotic and psychical 
states are properly attributable to the central or peripheral conditions 
of the pneumogastric nerve. 

Gastralgla, or Gastrodynia. — Aside from the stomach-pain of 
organic gastric disease, fermentation, and dyspepsia, there is a neurosis 
of the stomach marked by sudden pain in this viscus, to which the name 
nervous gastralgia is given by Ewald. It is not attended by the symp- 
toms of disturbed digestion, and the stomach contents at such times, as 
well as between the attacks, show nothing chemically irregular. It may 
alternate with other neuralgias or with migraine, or, rarely, it is associ- 
ated with an attack of the latter. It is occasionally presented by hys- 
terics, particularly if their attention is centered on the stomach. The 
gastralgic attack usually comes on promptly and reaches its highest 
intensity almost at once. The pain is an agonizing, boring, cutting, 
burning one, and may be localized, diffuse, or in a girdle. It may 
radiate along the loins or spine. The patients relax the abdominal 
walls and make deep pressure over the stomach with some relief, though 
there may be much superficial sensitiveness. Persistent sensitive spots 
are often found over the lower dorsal vertebrae, between the ribs, and 
by deep pressure over the abdominal plexuses of the sympathetic. The 
face is pale, distorted with pain, and covered with sweat. The tempera- 
ture is not modified. The attacks may be of only a few minutes' 
duration or may last for hours, and usually terminate rather abruptly, 
often with the vomiting of mucus or unchanged food. Food is then 
often actively craved and taken without distress. 

These rather rare attacks may very easily be mistaken for gall-stone 
colic, acute indigestion, gastritis, gastric ulcer, and a host of other abdom- 



DISEASES OF THE SPIXAL ACCESSORY NERVE. i^\ 

inal conditions which must be excluded to make the diagnosis possible. 
In locomotor ataxia they furnish the gastric crisis due in this disease to 
irritation of the pneumogastric nucleus in the medulla, where any other 
localized lesion may provoke them. They are, as a rule, associated with 
constipation. If due to organic nervous disease, the treatment and prog- 
nosis correspond. The same is true in hysterical cases. Otherwise the 
general upbuilding indicated in all neuralgic conditions must be at- 
tempted. 

Rumination, or merycism, is occasionally observed in man. The 
food is voluntarily regurgitated, remasticated, and again swallowed. 
It occurs in neurasthenics, hysterics, epileptics, and idiots. Usually the 
rumination begins a short time after the meal and lasts for half an hour. 
Such patients often insist that they are unable to control the habit, 
but, except in idiots, do so, at least to some extent, in the presence of 
strangers. 

Nervous dyspepsia, a condition set up by Leube as a gastric neu- 
rosis, is claimed by Ewald, and others equally competent, to be but a 
local manifestation of neurasthenia. Ewald points out that there is no 
peptic deficiency, and even Leube based his diagnosis largely on the fact 
that a meal is thoroughly digested and the stomach empty within the 
alleged normal limit of seven hours. The digestive difficulties of neu- 
rasthenia will be mentioned under that caption. 



CHAPTER IX. 

DISEASES OF THE SPINAL PORTION OF THE ACCESSORY 

NERVE. 

Anatomical Considerations. — The external portion or spinal part 
of the accessory nerve is, properly speaking, not a cranial nerve at all. 
Arising by a series of roots from multipolar cells in the anterior spinal 
gray matter throughout the cervical cord as low as the sixth segment, it is 
finally gathered into a bundle or trunk. This passes upward through the 
foramen magnum and joins the true accessory portion. It then passes 
with it through the jugular foramen, when it finally separates to be dis- 
tributed to the sternomastoid, which it entirely, and to the trapezius mus- 
cle, which it partly, furnishes with motor and trophic control. The trape- 
zius is also supplied by numerous spinal branches, particularly in its lower 
portion, and only depends on the spinal accessory in its upper half, though 
Bailey 1 reports a case in which division of the spinal accessory paralyzed 
the trapezius and sternomastoid completely and produced a serious disa- 
bility. This nerve may be centrally or peripherally affected, and the 
result is spasmodic or paralytic as the lesion is irritative or destructive. 

Accessory Spasm. — Spasmodic Torticollis, Spasmodic Wryneck. — Ir- 
ritative lesions of the spinal accessory produce characteristic action and 

1 "Ann. of Surg.," May, 1901. 



152 DISEASES OF THE CRANIAL NERVES. 

prominence in the muscles it supplies. By the sternomastoid the face is 
carried forward, turned toward the opposite side, and tilted upward. The 
trapezius draws the head backward and to the same side, lifts the shoul- 
der, and shortens the distance between the occiput and acromion. At 
the same time the scapula is drawn nearer the vertebral spines as well as 
upward. Both sternals acting together bring the head forward and 
downward. Both trapezii carry the head backward and the face up- 
ward. Acting alternately they turn the head from side to side with 
slight rotation. The spasm may be clonic or tonic, may involve one 
or both sides, and may be limited to the sternals or the trapezii. A tend- 
ency to spread to other muscles of allied function is often observed. As 
a matter of fact, in most cases of wryneck more muscles are involved 
than those supplied by the accessory nerves. Thus the splenius and the 
small rotators are frequently associated in the spasm, just as they are 
related functionally. The large muscles named are, however, the ones 
most at fault and the ones that impress a given case with its distinctive 
movement or attitude. The trapezius is less often clonically involved 
than the sternomastoid, but is as frequently affected by tonic spasms. 
In some cases clonic torticollis is a localized tic, or it may be a portion 
of a more widely distributed tic such as that arising in the face and 
gradually involving the neck, shoulder, and arm. In a mild form it 
furnishes the habit spasm that follows chorea sometimes or is picked up 
by pubescent youths. We may also have a mental torticollis as de- 
scribed by Bompaire, 1 in which the patient can not voluntarily restore the 
head to its natural position, but turns it readily in all directions if allowed 
to press it against any object, or to apply an insignificant amount of man- 
ual assistance. The spasm is here the result of a mental obsession. The 
nodding spasm of hysteria arises in the same way, and in both the 
disorder must be referred to the cortex or at least to the higher mental 
levels. In this connection the subject of Tics in Part VII. should be read. 
Cerebral tumors, meningitis, focal softenings, and disease of the medulla 
may underlie the spasm. Cervical spondylitis and meningitis usually 
produce tonic spasms. The action of cold, cervical adenitis, and violent 
wrenching of the neck may peripherally excite them. Torticollis has 
been reflexly produced by intestinal worms. 

Treatment is often highly unsatisfactory. The variety due to cold 
usually subsides spontaneously or may be benefited by local applications 
and antirheumatics. The hysterical form may suddenly cease. The cases 
dependent upon organic lesions are often beyond reach. Sedatives like 
cannabis indica, opium, and hyoscin only give temporary relief and often 
upset the stomach or, unfortunately, lead to their habitual use. When 
the spasm is severe, and especially if confined to one side, wide resection 
of the spinal accessory nerve before its entrance into the sternomastoid 
is advised, other means having failed. A tic or habit is thus likely to be 
benefited for a time, but is also likely to reappear in some adjoining area. 
Stretching the nerve is almost sure to be followed by a relapse of the tic 
as the nerve recovers, as is the case also if the divided nerve unites. 

1 "Thfcsede Paris." 



DISEASES OF THE SPINAL ACCESSORY NERVE. 



153 



The upper spinal nerves to the small rotators must in some cases also 
be divided to completely quiet the spasm. 

Children sometimes present a permanent wryneck of an entirely 
different character. Owing to traction on the head and twisting of the 



a 




1 



Fig. 61.— Difficulty in raising arm after division of left spinal accessory. 



^1 



neck in labor, or even in unaided labor, the sternomastoid may be in- 
jured, and subsequent contracture shortens it. The result is a firm, 
fibrous band that holds the face to the opposite side. Inflammatory 
injury to the muscle in adults may cause the same thing, and in both 
cases it can be remedied only by thorough 
division of the shortened tissues. 

Accessory Paralysis. — Cortical disease 
very exceptionally results in complete and 
permanent loss of power in the spinal ac- 
cessory area. Like those of other bilateral 
movements, these muscles seem fully repre- 
sented in both hemispheres. As a part of 
nuclear disease, as in progressive muscular 
atrophy, the spinal centers are often involved, 
with a corresponding loss of power and nu- 
trition. Bv meningitis the trunks of one or 
both nerves may be implicated at the fora- 
men magnum. The hypoglossal is then 
likely to suffer with them, and the true ac- 
cessory fibers are usually also affected. Out- 
side the skull the spinal portion of the ac- 
cessory is sometimes involved in wounds, 
operations, deep-seated tumors, vertebral 
caries, cervical adenopathy, and by neuritis, 
are loss of power and wasting in the related muscles. This involves 
the sternomastoid almost entirely and the trapezius only in its upper 
portion. The head is not so readily and strongly turned to the opposite 





62. — Drooping shoulder, 
lengthening of neck, and rotation 
of scapula after division of left spinal 
accessory. 



The unilateral symptoms 



154 DISEASES OF THE CRANIAL NERVES. 

side, the shoulder droops slightly, and the extension power of the arm 
is lessened. The scapula moves outward, especially its upper inner 
angle, and stands out from the ribs. The curved line from mastoid to 
acromion becomes depressed and even angular upon efforts at deep in- 
spiration or in extending both arms against resistance. Subsequent 
contracture in the unopposed muscles of the sound side may turn the 
face to the primarily affected side. 

In the bilateral form, usually due to meningitis or vertebral caries, 
the head is held insecurely and readily falls forward or backward as the 
trapezius or sternals are most affected. Injury to the spinal accessory 
in the posterior triangles of the neck after it has passed through the 
sternomastoid only affects the trapezius. The treatment is that of the 
causal condition in the given case. In neuritis electrical stimulation is 
indicated, and nerve-suture would be required in the cases where the 
nerve had been divided. 



CHAPTER X. 
DISEASES OF THE HYPOGLOSSAL NERVE* 

Anatomical Considerations. — The twelfth cranial nerve is a 
purely motor nerve for the muscles of the tongue and subserves their 
nutrition. Its cortical centers adjoin those for the lips in the lower 
portion of the ascending frontal gyre. Its lower neuron arises in the 
hypoglossal nucleus under the floor of the fourth ventricle. This nu- 
cleus is close to the median line, and is made up of large cells analogous 
to those in the anterior spinal horn of gray matter. The nerve-trunk 
arises by a number of roots in the groove outside of the olivary body, 
and, passing forward, leaves the skull by the anterior condyloid fora- 
men of the occipital bone. It has a connection with the pneumogastric, 
which it accompanies a short distance, and receives a branch from the 
upper spinal nerves. This branch eventually innervates the depressors 
of the hyoid bone, and is not affected by injury to the hypoglossal 
nucleus. The hypoglossus may be injured or diseased in any part of its 
course from the cortex to the peripheral branches, and manifests such 
injury by spasm, paresis, and paralysis, as the causal state is irritant, 
inhibitive, or destructive. In addition, injury at or below the nucleus 
entails atrophy of the muscular fibers of the tongue. The mucous por- 
tion of the tongue is supplied by the trifacial. 

Hypoglossal Spasm. — The tongue is usually involved in epileptic 
convulsions, and is frequently bitten in consequence of having been 
thrust between the teeth by the action of the genioglossus muscles and 
lacerated by the spasmodic action of the masticators. This may occur 
in very slight attacks, when no convulsive action in the extremities is 
observed. At an early stage of hysterical convulsions the tongue is 
usually protruded violently, but is only bitten in extremely rare cases. 
This lingual spasm may comprise the entire motor disturbance in some 
hysterical cases. In chorea the tongue is usually involved in the mus- 
cular twitchings that mark the disease, and is often the seat of vigorous 



DISEASES OF THE HYPOGLOSSAL NERVE. 155 

choreic movement, in which it may be protruded and even slightly 
bitten. The speech difficulties of this disease are due in part to the 
lingual spasm. From forced overuse, as in public speakers, it is some- 
times the seat of a neurotic manifestation similar to writers' cramp, a 
condition termed aphthongia. Slight spasm also occurs in stammering 
and in stuttering. Lingual spasm has been reflexly dependent upon de- 
cayed teeth and cured by their removal. 

Cortical irritation has, in rare instances, given rise to lingual spasms 
that practically constitute Jacksonian epileptic attacks. The lips and 
face usually participate in the spasm, as the contiguity of their centers 
would lead one to expect. In some of these cases the initial convulsion 
has been a generalized fit ; in others such attacks have followed. It is 
conceivable that nuclear irritation might give rise to similar manifesta- 
tions, but post-mortem data for this belief are lacking. The treatment 
would be that of the general condition underlying the local manifestation. 

Hypoglossal Paralysis. — The hypoglossus nerve may be paralyzed 
by injury at any point in its course. In rare cases a limited cortical 
lesion has produced paralysis of the opposite side of the tongue. More 
wide-spread cortical lesions and lesions in the supranuclear motor tract 
usually produce a one-sided paresis or paralysis of the tongue, which, on 
protrusion, deviates toward the paralyzed side, — that is, away from the 
lesion. This is due to the action of the unaffected and properly acting 
genioglossus of the sound side. Nuclear disease usually produces bi- 
lateral palsy of the tongue, which lies motionless in the floor of the mouth, 
and, after a few days, rapidly wastes. A few cases of one-sided nuclear 
disease are recorded. In bulbar palsy, syringomyelia, and tabes it is 
thus affected in exceptional cases. Other cranial-nerve nuclei usually 
suffer at the same time, and the resulting symptoms enable one to 
localize the disease. The fibrillar twitchings in the tremulous tongue 
of paretic dementia and some of the stammering of this malady are due 
to the nuclear and cortical invasion of the disease. The root of the 
nerve in its passage through the medulla is sometimes damaged by a local 
lesion, which of necessity interferes with the pyramidal tracts for the 
opposite side of the body and produces a crossed paralysis of the tongue 
and limbs. The tongue, in such an instance, would deviate from the 
paralyzed side of the body and toward the side of the lesion. Such a 
crossed palsy, due to disease of the olivary body, has been reported. 1 
Basilar processes, like meningitis and fractures, or bone disease involv- 
ing the condyloid foramen, may injure the nerve in its intracranial 
course. Outside of the skull it is vulnerable to penetrating wounds, or 
may be implicated in deep abscesses, as from caries of the upper verte- 
bra?. Here its neighbors, the spinal accessory and the pneumogastric, 
are likely to be involved at the same time. It may be affected by a 
neuritis as in a case reported by Panski, 2 who was able from the litera- 
ture to collect 40 cases of isolated hypoglossus paralysis due to periph- 
eral disease or injury. 

In unilateral hypoglossal paralysis due to damage of the nerve at or 
below the nucleus, the paralyzed side of the tongue shows a marked 

1 G-oukoYsky, " Nouvelle Iconographie de la Salpetriere, " Xo. 3, 1895. 

2 "Xeurolog. Centralbl.," Aug., 1903. 



156 DISEASES OF THE CRANIAL NERVES. 

loss of volume. This does not follow supranuclear lesions. The mucous 
covering, on the other hand, not being deprived of its trophic supply, is 
thrown into marked and apparently excessive folds. Taste and sensation 
are not impaired. Mastication on the paralyzed side of the tongue is not 
well performed, as the patient finds difficulty in placing and maintaining 
the food between the teeth. When protruded, the tongue curves sharply 
to the wasted side, but within the mouth motions toward the palsied side 
are wanting. In the bilateral form speech is much affected, as nearly 
all consonant sounds depend in some degree upon the position of the 
tongue. Swallowing is also difficult, as the bolus or fluid is not readily 
carried backward into the pharynx and mastication is greatly impeded. 
Treatment is directed to the causal condition, aside from which it 
is practically hopeless. 



CHAPTER XI. 
MULTIPLE PARALYSES OF CRANIAL NERVES* 

In discussing the cranial nerves separately, frequent reference has 
been made to their association in diseased processes. Sometimes the 
limitation of this association is of diagnostic importance, as when the 
loss of hearing with facial palsy locates a lesion of the seventh and 
eighth nerves in their parallel intracranial course or within the internal 
meatus auditorius. In meningitis and other basilar processes a number 
of cranial nerves are usually implicated at once, and such multiple 
paralyses of cranial nerves become symptomatically highly important. 
The close juxtaposition of the cranial nuclei has been repeatedly pointed 
out as giving rise to associated palsies in bulbar disease, such as tumor, 
hemorrhage, and limited basilar thrombosis. In their cortical fields 
and their supranuclear motor paths a number of the cranial nerves may 
also be injured at once by traumatism or disease. Hypoglossal palsy 
with hemiplegia has just been called to attention, as well as the 
association of hypoglossal and facial spasm due to the cortical relations 
of their centers. These multiple cranial palsies are principally of symp- 
tomatic interest and value, but there are groups of nuclear palsies of 
the cranial nerves that present well-marked clinical forms of disease. 
Their pathological anatomy is largely confined to the upward extension 
of the spinal gray that furnishes the chain of cranial-nerve nuclei 
reaching from the lower angle of the floor of the fourth ventricle to the 
posterior portion of the third. Anatomically and clinically these dis- 
eases fall into two forms : First, those of the upper group, primarily 
implicating the nuclei of the third, fourth, and sixth nerves (see 
Fig. 36), and, second, those first implicating the remaining lower cranial, 
nuclei. As these diseases are sometimes inflammatory in character and 
analogous to poliomyelitis, they have come to be known respectively as 
polio-encephalitis superior and polio-encephalitis inferior. More com- 
monly the process is one of degeneration. The analogy, or in some 
cases the identity, of the disease of the nuclei of the bulb with that of 
the anterior gray of the cord is now generally conceded. It is the same 
process arising in different localities, but affecting homologous elements 



MULTIPLE PARALYSES OF CRANIAL NERVES. 157 

and producing results similar in kind. Transition and combination 
cases of every variety are of record. Commencing in the upper nuclei 
of the ocular nerves, the lower bulbar levels may be progressively in- 
vaded, and later spinal features may be added; or, beginning in the 
bulbar nuclei, an upper extension may induce progressive ophthal- 
moplegia. In the same way that the spinal type of the disease may 
be acute, subacute, and chronic, we have an acute, subacute, and chronic 
polio-encephalitis superior and inferior, and forms combining both. 

Polio-encephalitis superior chronica will be considered first, as it 
presents the most complete and well-defined picture. It is also called 
progressive ophthalmoplegia and chronic nuclear ocular paralysis. It is 
characterized by the gradual loss of power in the external and internal 
muscular apparatus of the eyeball, one set of muscles after another 
being gradually involved. Usually bilateral, it may be confined to one 
eye for a period even of years and then invade the other. As a rule 
progressive, it may come to a permanent standstill at any time, or ad- 
vance intermittently. 

Etiology. — Polio-encephalitis superior has in so many cases followed 
infections and toxic states that it has with reason been attributed in some 
cases to pneumonia, grip, diphtheria, and syphilis ; to lead, sulphid 
of carbon, carbonic-oxid gas, sulphuric acid, and alcohol. A careful 
search for syphilis by blood and spinal fluid tests indicates a greater 
relationship to this infection than was formerly supposed to be the case. 
These toxic agents, however, are more common in the causation of the 
acute variety, which may terminate by becoming chronic. It may be 
secondary to or a part of tabes dorsalis, and the characteristic Argyll- 
Robertson pupil of that disease is a part of it. It is similarly related 
to posterolateral spinal sclerosis, general paresis, and insular sclerosis. 
It may be an upward extension of identical disease in the cord or bulb. 
It is more frequent in men than in women, and while it may appear at any 
age, it is principally a disease of adult life. In some cases there seems 
to be a teratological defect, congenitally manifest or appearing during 
the active periods of growth. 

Pathological Anatomy. — The lesions are variable in extent. They 
involve the upper cranial-nerve nuclei on one or both sides, including 
those of the third, fourth, and sixth nerves, wholly or in part. AVhen 
partial, the iridociliary nucleus of the third and its adjoining nucleus for 
the elevator of the lid most frequently escape or are only partly des- 
troyed. The corresponding nerve-trunks and muscles are degenerated 
and atrophied. In addition are encountered cerebral, bulbar, and spinal 
conditions, of which polio-encephalitis superior sometimes is but a part. 
Microscopically, especially in the early stage, some hyperemia is found 
about the nuclei. Later the cells of these nuclei lose their prolonga- 
tions, are diminished in size, present vacuoles and pigmentary degenera- 
tion. Some completely disappear, and in cases of long standing but a 
few atrophied remnants remain. Slight capillary hemorrhages or their 
traces can at times be determined. Some leukocytal infiltration occurs 
about the vessels or in the foci of the disease, and minute sclerotic patches 
are found. Rarely the lining of the Sylvian aqueduct is thickened. 

Symptoms. — In the fully-developed cases the facies, classically de- 



158 DISEASES OF THE CRANIAL XERVES. 

scribed by Hutchinson, and recognized by Brunner, von Graefe, Char- 
cot, and others, is most striking. The drooping lids partly covering the 
eyes cause the patient to hold the head back and strain with the frontalis 
to overcome the partial ptosis. The brow is thrown into deep trans- 
verse wrinkles. The immobile eyes and inactive pupils are like those 
of glass in a mask of wax. They usually deviate outward, as the sixth 
nucleus is often spared at first ; but any squint may in various cases 
be present or the visual axes may conform. The ptosis is usually less 
marked after a night's rest ; and if the ocular muscles still retain a slight 
degree of activity, this, too, is best in the morning. Diplopia is rarely 
mentioned by these patients, which Blanc attributes to the slowness with 
which the deviation develops, thereby allowing the brain to neglect one 
image. In partial cases the ocular conditions may be unilateral or they 
may be only functionally distributed and bilateral or unilateral. Thus 
the iris may react for light or accommodation, or both. The abducens 
may at first escape or first be involved, and innumerable combinations 
and varieties have been encountered as one or many nuclei were par- 
tially or completely affected. 

The general health of the patient may leave little to desire or he may 
present the somatic conditions and functional disturbances that belong 
to the associated diseases already mentioned. In some instances involve- 
ment of the fifth nerve, probably through its descending root, has given 
rise to paresthesia or anesthesia in the face. 

Course. — The evolution of the disease is one of its most distinctive 
features. Commencing with a ptosis or a squint, the other features of 
the disease are gradually added during, perhaps, several years. Sta- 
tionary periods of long duration — twenty-five years in a case of Striim- 
pelPs — may intervene, and finally the disease takes up its progressive 
course, perhaps without appreciable cause. Extensions of the process 
to the bulbar region may occur, and we have bulbar palsy or polio- 
encephalitis inferior added and the prognosis for life becomes much 
darkened. The lesions may not stop at the bulb, but may invade the 
cord, producing a progressive spinal muscular atrophy of any one of the 
various types of that disease. 

The diagnosis depends largely upon the evolution of the disease 
and its progressive course. When thoroughly developed its remarkable 
facies is not easily mistaken. The acute form, and hemorrhage, inflam- 
mation, and softening, give a history of rapid onset and promptly reach 
their maximum stage. In multiple neuritis, especially the alcoholic 
and diphtheric varieties, confusion is likely to arise, but we may gener- 
ally be guided by the condition of the extremities and the wide diffusion 
of the disease. Even then we can not absolutely exclude the cranial 
nuclei, which may become the seat of a chronic atrophic process. An 
orbital tumor may give rise to a partial and increasing ophthalmoplegia, 
but pressure symptoms, exophthalmos, and optic atrophy will finally 
distinguish it. Basilar processes and bulbar growths, aside from the 
distinctive symptoms to which they give rise, usually implicate so many 
nerves and the pyramidal tracts that they can be easily separated. 

Treatment turns practically upon the presence or suspicion of 
syphilis, which should be vigorously managed. Other toxic possibili- 



MULTIPLE PARALYSES OF CRANIAL NERVES. 159 

ties, such as lead-poisoning, will require appropriate intervention. 
Strychnin does temporary good sometimes. Electricity is futile, as it 
can not be applied to the faulty muscles. In the majority of cases the 
physician is helpless. 

Acute and Subacute Polio-encephalitis Superior. — The acute 
form is very rare. Like its congener, acute poliomyelitis, it may be 
purely an infectious disease, and has been noted in epidemics of the 
spinal disease. It may follow many acute infections, as mentioned in 
the etiology of the chronic form, especially diphtheria, pneumonia, and 
influenza. The subacute form, while in some cases attributable to the 
above causes, is more often due to syphilis and toxic agents, like lead 
and the carbon gases. The onset is sudden or very acute, and the 
disease may reach a fatal termination in a few days or a week, usually 
from implication of the bulbar centers. The nuclei in several such 
cases have presented no post-mortem changes that could be discovered. 
Brissaud * supposes that the infection has overwhelmed the nuclei be- 
fore histological traces discoverable by our present means of investi- 
gation were developed. The similarity to Landry's paralysis in this 
regard is striking, and the diseases may be essentially the same, varying 
only in localization. In other cases well-marked inflammatory changes 
have been discerned. The prognosis is very grave, especially in chil- 
dren. Some cases come to a standstill ; others develop into the chronic 
variety. 

The treatment should be directed to securing perfect rest and the 
removal of any source of infection or intoxication and ks eradication 
from the system before important changes occur. 

Polio-encephalitis inferior chronica is the term employed by 
Wernicke to denominate the disease first described by Dumesnil, later by 
Duchenne, as progressive paralysis of the tongue, palate, and lips. It is 
also known as labioglossolaryngeal or pharyngeal paralysis (Leyden), 
as progressive bulbar paralysis (Wachsmuth), as paralysis of the bulbar 
nuclei (Kussmaul), and as progressive bulbar palsy. It consists in a 
progressive paralysis of the lips, tongue, pharynx, and larynx, with 
wasting of their muscles, and usually terminates in death from pneu- 
mogastric palsy. * The disease process is limited to the nuclei and lower 
neurons of the seventh, ninth, tenth, eleventh, twelfth, and the motor 
portion of the fifth cranial pairs. It is identically the same in charac- 
ter with progressive spinal muscular atrophy, with which it is often 
associated. 

Etiology. — Males and females are about equally susceptible to this 
disease. Though it has rarely been observed in childhood and may be a 
congenital or teratological deficiency, it usually appears after the age of 
thirty. Occasionally, and then ordinarily as a part of a more extensive 
spinal atrophy, or in association with superior polio-encephalitis, it has 
appeared in successive generations or in more than one member of the 
same family. These family cases usually develop in early life. It has 
been attributed to exposure to cold ; to the overuse of the mouth-muscles, 

1 "Lecons," 1895. 



160 DISEASES OF THE CRANIAL NERVES. 

as in players of wind-instruments and glass-blowers; to syphilis, to 
B right's disease, and other wasting maladies. It may be a part of 
amyotrophic lateral sclerosis. It has appeared in tabes dorsalis, in- 
sular sclerosis, syringomyelia, and followed descending degeneration of 
the pyramidal tracts after cerebral lesions. Knowledge of the role of 
toxemia in these chronic disturbances is widening. Progressive bul- 
bar palsy has been known to follow lead intoxication and diphtheric 
poisoning. Often the causation is entirely obscure, but advances in the 
field of auto-intoxication may throw light on this darkness. 

Morbid Anatomy. — The lesion is limited to the nuclear cells in the 
lower half of the bulb. It is practically symmetrical. The hypo- 
glossal nucleus is most severely affected, as a rule. The nuclei of the 
true spinal accessory, the facial, the motor portion of the trifacial, and 
the pneumogastric are invaded with decreasing intensity and frequency. 
A degenerative process is found in the nerve-trunks whose nuclei are 
affected and their muscular terminations waste. The muscle-fibers 




MMKA 



Fig. 63. — Case of bulbar palsy. 1, Photograph taken shortly before first symptoms were noted; 2, pho- 
tograph taken four years later, a few weeks before death. 

themselves show corresponding degeneration and atrophic conditions. 
The minute anatomy is the same as that in progressive ophthalmoplegia 
or that of progressive spinal muscular atrophy, to which the reader, 
bearing in mind the special location of this disease, is referred. The 
organic changes of associated atrophies and scleroses or of primary con- 
ditions, such as tabes, syringomyelia, insular sclerosis, and descending 
cerebral degenerations are at times encountered. 

Symptoms. — The symptoms begin insidiously and progress slowly. 
The tongue is usually the first affected. This is manifest in a thick- 
ened pronunciation, particularly of the letters which require definite 
lingual movements. The linguodentals and linguopalatals (see table, 
p. 67) and the vowel "e" and later on the explosive labial sounds are 
lost. Finally speech is reduced to unmodified laryngeal noises that are 
quite unintelligible. When the disease is only slightly developed, by an 
effort the patient can often enunciate clearly and the embarrassment may 
be noticed only in ordinary inattentive conversation. The tongue also 
progressively loses its muscular strength and range of motion until it 



MULTIPLE PARALYSES OF CRANIAL NERVES. 



161 




lies a flabby, inert, rugose, atrophic mass on the floor of the mouth. It 
loses its function of maintaining the food between the teeth during mas- 
tication and of carrying the bolus backward and thrusting it into the 
pharynx in efforts at swallowing. It can no longer be protruded, 
turned to either side, rolled up, or hollowed into a gutter. In most of 
the cases it notably wastes, but as the atrophy is confined to the mus- 
cular portion of the tongue, the dermal covering appears too large and 
may even suggest epidermal hypertrophy. 

The lips are affected shortly after the tongue, and this adds to the speech 
difficulty by rendering the pro- 
nunciation of the vowels "o" and 
" u " uncertain or impossible. 
The labial consonants are lost as 
above indicated, and little be- 
sides the sibilant "s" and the 
open vowel " a " remain. The or- 
bicularis oris is usually the first 
labial muscle invaded, but all 
of the labial group are even- 
tually paralyzed. Their nuclear 
association with the hypoglossus 
and their functional relationship 
will be recalled. At first whist- 
ling and blowing efforts are 
weakened, but finally the mouth 
hangs loosely, the lower lip 
drooping away from the teeth, 
and all voluntary movements 

are lost. This, with the action and eventual contracture of the zygoma- 
tics, serves to greatly accentuate the nasolabial furrows and imparts a 
demented appearance to the lower portion of the face. 

Out of the drooping, open mouth saliva drules, requiring the constant 
use of a napkin or handkerchief. The quantity is sometimes enormous 
and always appears greater than normal. When the masseters and 
pterygoids are involved, which is usually at a late stage, but may be an 
initial condition, mastication is feeble or impossible. Finally, their 
complete paralysis allows the mandible to hang loosely, increases the 
opening of the drooping mouth and the salivary overflow. The jaw- 
jerk is abolished except in those cases where spastic symptoms elsewhere 
point to the association of the pyramidal tracts in the lesion. It is 
then increased. The lips usually show marked atrophy and are sensibly 
thinned. This is sometimes obscured by the fatty deposit, but in the 
final stages is practically a constant condition. 

The palate follows the lips in order of involvement in a majority of 
cases. Its loss of muscular tone is manifested by the nasal voice tones, 
which also adds to the lack of clearness in the pronunciation of the linguo- 
palatals, and it turns " p " and " b " into the nasal resonant " m." When 
the palate is fully palsied it hangs loosely in the pharynx without reflex 
action or voluntary movement. As it can no longer shut off the nasal 
11 



Fig. 64. — Mouth in bulbar palsy. Voluntary maxi- 
mum opening and attempt to project the tongue,which 
lies inert and shrunken in the floor of the mouth. 



162 DISEASES OE THE CRANIAL NERVES. 

spaces, fluids often regurgitate through the nose, and even food masses 
may be forced into the nasal fossae. 

When the pharynx is involved, the difficulties of swallowing reach 
their maximum. Food is now prone to enter the respiratory tract and 
a violent fatiguing, and alarming cough is often produced. The danger 
of pulmonary engorgement, aspiration pneumonia, and heart-failure is 
intensified by the pneumogastric weakness that is often present. Alimen- 
tation becomes so difficult that the esophageal tube must be used or the 
patient must be fed by the bowel. To these difficulties is added, sooner 
or later, a paralysis of the larynx. The adductors are usually most 
affected and the glottis stands wide open, serving neither the purposes 
of phonation nor protection to the trachea against the entrance of foreign 
material. In very rare cases unilateral or bilateral abductor palsy is 
found, and in the latter case inspiratory stridor indicates the dangerous 
respiratory difficulty. Both pharyngeal and laryngeal reflexes are 
abolished. The voice is extinguished. Failing respiratory and cardiac 
actions lead to a fatal termination, which may come suddenly at any 
period of the disease. It is often induced by aspiration pneumonia or 
caused by suffocation due to blocking of the respiratory passage by a 
mass of food. 

The pulse is likely to become frequent, weak, and irregular. True 
anginal attacks are not infrequent. Syncope may occur and prove fatal. 
The pneumogastric involvement further shows itself in a feebleness of 
respiration, so that coughing and other active expiratory efforts become 
almost impossible, adding greatly to the danger of choking and to the 
general discomfort of the patient. It is somewhat remarkable that 
polyuria and glycosuria are seldom encountered. The controlling 
centers in the bulb are in close proximity to those invaded by this 
disease. It will be noticed that the nuclei selected are purely motor and 
trophic, and that the disease spreads not so much by contiguity as along 
lines of associated function. This is one of the distinctive habits of the 
disease, and serves here, as in other progressive maladies of the cerebro- 
spinal axis, to draw earnest attention to this factor in the study of every 
case. 

The electrical examination of the atrophic muscles presents consider- 
able difficulty, excepting in the lower face and the masseters. The 
changes found are practically a quantitative reduction to all currents as 
fiber after fiber disappears. The reaction of degeneration is wanting. 
The reflexes are diminished in a degree proportional to the atrophy, ex- 
cepting in those cases in which the disease early involves the pyramidal 
tracts. Sensation is not markedly affected, nor is the sense of taste notably 
disturbed in pure cases. The temperature remains uninfluenced through- 
out, save by intercurrent accidents. 

Course. — The disease is one of insidious onset and its steadily progres- 
sive course is characteristic. In a few exceptional cases the progress of the 
disease presents intermissions, but remissions are practically unknown. 
The duration of the malady from inception to fatal termination may be 
roughly stated as from one to five years. Leyden reports one case of 
seven years 7 duration, but, on the other hand, intercurrent maladies and 



3IULTIPLE PARALYSES OF CRANIAL NERVES. 163 

the suffocative, cardiac, and pulmonary accidents to which the disease 
lays the patient liable may cut life short at any moment. The increas- 
ing feebleness and malnutrition at the same time add to the gravity of 
the situation. As above indicated, the disease first manifests itself in 
the tongue and progressively invades the lips, pharynx, palate, masti- 
cators, and larynx. This is a usual sequence, but not a necessary one. 
Any modification of it may be presented. The encroachments of related 
nuclear disease at lower and higher levels give rise to different trains 
of symptoms, which, however, in their full development furnish very 
similar pictures. The course pursued in any given case can be under- 
stood by reference to the anatomical and especially to the functional 
relationship of the bulbar nuclei. The occurrence of a bronchitis, 
bronchopneumonia, angina pectoris, or of suffocative attacks is often of 
fatal import. 

Diagnosis. — The diagnosis of a well-developed and unmixed case 
presents little difficulty. The course of the disease is of the first impor- 
tance. The facies can hardly be mistaken. Palsy of both facial 
nerves gives rise to feebleness of the lips, but the upper part of the face 
does not escape and glossopharyngeal symptoms are lacking. Diph- 
theric palatal palsy may raise a doubt unless the clinical history of the 
infection is available. In this condition the lips and tongue escape, the 
onset is somewhat abrupt, and the usual course is toward recovery. 
Great difficulty may be presented in cases of multiple neuritis, but in 
them we have sensory disturbances, the reaction of degeneration, and 
marked symptoms in the extremities. When secondary to tabes, insular 
sclerosis, syringomyelia, and amyotrophic lateral sclerosis, the highly 
characteristic symptoms of these various diseases are prominent. As 
an extension process from the cord upward, or from the ocular nuclei 
downward, its development is preceded by the well-marked evidence 
of these prior states, which persist and increase during the evolution of 
the bulbar paralysis. The greatest diagnostic difficulty is presented by 
cases of the pseudobulbar paralyses. 

Treatment. — In pure polio-encephalitis inferior chronica the prog- 
nosis is fatal. Curative treatment is, therefore, out of the question, 
but much can be done to alleviate the distressing condition of the 
patient and to obviate the laryngeal, pulmonary, and nutritive dan- 
gers that threaten him with suffocation, asphyxiation, pneumonia, and 
inanition. The hypersecretion of saliva may be checked bv atropin, 
which also furnishes a reliable heart-stimulant. The stomach-tube and 
rectal alimentation are our means to avoid strangulation and to secure 
nutrition. Recourse to tracheotomv may be had in abductor laryngeal 
paralysis. Electricity is of use in exercising the muscles of the face, 
tongue, and gullet. The faradic current is sufficient. The large, indif- 
ferent electrode may be placed on the back of the neck, and a smaller, 
active electrode is then brought into contact with the lips, masseters, and 
tongue. By placing it over the pomum adami swallowing efforts are 
induced. Care must be exercised not to fatigue muscles already wasted. 
Energetic courses of silver, ergot, phosphorus, zinc, picrotoxin, and 
mercury, except mercury and arsenic in specific cases, are mentioned 



Ig4 DISEASES OF THE CRANIAL NERVES. 

only to condemn them, and anything else that pulls down the waning 
strength of the patient must be avoided. Tonics, rest, and strengthening 
measures are of value. 

Acute bulbar palsy, or acute bulbar myelitis, is due to the same 
infections that set up acute myelitis. It may furnish the terminal stage 
of the chronic form, or it may result from an upward extension of a 
cord-lesion. The symptoms with which we are familiar in the chronic 
variety are rapidly evolved and often associated with febrile disturb- 
ances, headache, and somnolence. As the disease gains the pneumo- 
gastric nuclei, death becomes imminent and results through respiratory 
failure. 

Combined Forms of Polio-encephalitis. — The various combi- 
nations of chronic superior and inferior polio-encephalitis by extension 
have been alluded to in describing them separately. In some very rare 
cases the nuclear invasion falls upon upper and lower cranial nuclei 
practically at once. The resulting picture is an aggregate of the simpler 
ones. From their vital nature, the presence of pneumogastric symptoms 
dominates the outlook. 

Pseudobulbar Paralyses. — These are (1) organic and (2) asthe- 
nic. The organic variety is due to more or less symmetrical lesions 
involving the posterior group of cranial nerves at any point from their 
cortical centers to their peripheral trunks. We distinguish a cerebral 
form due to bilateral cortical or subcortical vascular lesions. The onset 
is abrupt, and usually developed in two stages. A hemiplegic or apo- 
plectic case presents a second stroke, this time from a lesion in the sound 
hemisphere, and the bulbar palsy is at once established or completed. 
It is only very rarely limited to the parts definitely elected by true 
bulbar palsy, does not present the atrophy or degenerative reactions, and 
the reflexes are retained or exaggerated. A radicular form follows acute 
bulbar myelitis and hemorrhage into or softening of the bulb. These 
are rare affections of sudden onset. The lesion does not spare the motor 
tracts for the limbs, and other bulbar functions do not escape. Tumor 
may similarly produce a pseudobulbar palsy, but the distinctive symp- 
toms of an intracranial growth — headaches, vomiting, vertigo, and pap- 
illitis — are added. A basilar form is occasioned by tumors of the base 
and basilar meningitis, especially of the syphilitic variety. A pseudo- 
bulbar paralysis of this form is among the greatest rarities, for obvious 
anatomical reasons. Finally we have a neuritic form. This is usually 
only a part of a more widely distributed or multiple neuritis. 

Asthenic Bulbar Paralysis (Myasthenia Gravis). — This disorder, 
as described by Strumpell, 1 may mimic chronic polio-encephalitis in- 
ferior very closely, but is never so definitely limited to the cranial nerves. 
Previous to his communication a similar case was reported by Jolly, 2 
under the title of " Myasthenia Gravis Pseudoparalytica." Since that 
time cases have been reported by Murri, 3 Pineles, 4 Bruns, 5 Collins, 6 
Hallervorden, 7 Kojewnikoff, 8 and many others. 

1 "Deut. Zeit. f. Nervenheilk.," Bd. 8. 

2 " Berlin, klin. Wochens.," Jan. 7, 1895. 3 "Policlinico," vol. ii, 1895. 

4 "Wien. Jahrbuch f. Psychiat.," vol. xiii. 5 Schmidt's " Jahrbuch," 1896. 

6 "Internat. Med. Mag.," April, 1896. 7 " Archiv f. Psychiatric," vol. xxviii. 

8 "Deut. Zeit. f. Nervenheilk./' Nov., 1896. 



MULTIPLE PARALYSES OF CRANIAL NERVES. 165 

The condition in most instances has terminated fatally; but no 
changes in the bulbar nuclei were discovered. Apparently the deficit 
or toxic effect had not reached a degree sufficiently intense to produce 
cell-changes that were observable under ordinary methods of examina- 
tion. In a case reported by Widal and Marenesco, 1 disintegration of 
the chromophilic elements was demonstrated by the Nissl and Marchi 
methods. Goldflam 2 found widespread and decided changes in the 
muscles. This case and one reported by Long and Wicki presented 
preceding chronic pulmonary septic conditions, and this association is 
probably not uncommon. The asthenia of phthisis pulmonalis may run 
into a grave myasthenic condition, as I have seen in one case which pre- 
sented all the characteristic bulbar features. Laquer and Weigert have 
also noted widespread changes in the muscles apparently secondary to 
thymus disease. Laquer reports a case followed by progressive spinal 
muscular atrophy. Senator 3 suggests a relationship to various depraved 
blood states. Remak refers to a case of associated Graves' disease. 
Feinberg reports a case in which stercoremia was present and the asthenic 
symptoms retreated upon its relief. A persistent and enlarged thymus 
gland has been found so frequently, generally in association with wide- 
spread intramuscular infiltration of cells of a lymphoid character, that 
more than a casual relation seems to be implied between the myasthenia 
and the glandular state. Von Ketly, 4 after a study of 134 cases with 42 
autopsies collected from the literature, concludes that a neuropathic 
heredity is practically the only common antecedent, that the nervous 
system is intact, and that the muscles are the seat of the disease, which is 
the result of some auto-intoxication. Csiky 5 finds that the reported 
cases of this lymphoid state may be divided (1) into such as present a 
primary tumor in some part of the body and (2) those which have no 
such association. The second group is much the larger. Buzzard has 
found the lymphoid infiltration in the heart, liver, adrenals, and thyroid. 
An intimate relation of the disease to exophthalmic goiter and associated 
disorders of the glands of internal secretion is emphasized by Stern. 6 

The paralysis, which comes on more or less insidiously, especially 
involves the tongue, lips, and pharyux, but the eyes and extremities are 
also affected to a certain degree, and sometimes very decidedly, and weak- 
ness of the muscles of the neck is a notable symptom. Ptosis is commonly 
encountered early. Usually, indeed, the myasthenia is general. Fibril- 
lary twitching is wanting, and the reflexes are not disturbed, 7 except- 
ing that, if repeatedly elicited, they tend to fail through the induced 
muscular fatigue. Electrical responses are only modified by the 
fatigue induced by their repetition, presenting the myasthenic reaction, 
especially to the faradic current. It is found, as in bulbar paralysis, 
that rest seems to improve the paralytic features, but that the muscles 

1 "Presse med.," April 14, 1897. 

2 "Neurol. Centralbl.," Feb. 1, 1902. 

3 "Berlin, klin. Wochens.," 1899. 

4 "Deut. Zeit. f. Nervenheilk.," Nov., 1906, Bd. 31. 

5 "Deutsch. Zeitschr.," Bd. 37, page 175. 

6 "Neurol. Centralbl," April 1, 1914. 

7 Oppenheim, "Myesthenische Paralyse," Berlin, 1901. 



166 



DISEASES OF THE CRANIAL NERVES. 



involved show an extraordinary susceptibility to fatigue. Jolly's 
case showed regular muscular exhaustion under electrical stimulus, 
and this has been generally found in other cases. 1 In most instances 
there is a tendency to improve and to relapse, as in the case of Collins, 
in which case the special senses of sight and hearing also showed rapid 
exhaustion. E. F. Buzzard, 2 in a study of five cases, noted decided 
sensory disturbances of a tabetic distribution in one, and fleeting areas 
of paresthesia and analgesia in others. Localized atrophies are also pos- 
sible and certain changes in the muscle fibers indicate early amyotrophic 
conditions. In all his cases various muscles and organs showed lymph- 
ocytic infiltration, though thymus glandular anomalies were not always 
present. Mental disturbance of a mild order has also been encountered. 




Fig. 65. — Myasthenia gravis in an advanced case. 1, Mask-like, expressionless face, drooping eye- 
lids, etc.; 2, forced attempt to smile vigorously ; 3, forced attempt to close eyes firmly and to protrude 
tongue vigorously : it passed the lips with difficulty ; the eyeballs were hardly covered. 



The condition is marked essentially by asthenia, affecting particularly 
the motor apparatus. The prognosis is grave; a fair proportion of the 
cases terminate fatally through asphyxia. In the treatment, rest is 
advised with correction of any toxic or septic factor that may be dis- 
covered. The free administration of strychnin is probably harmful. 
I have seen the tendon reflexes repeatedly disappear under its use by 
the hypodermatic method, returning regularly upon its withdrawal. 
Spermin, electricity, massage, and prolonged rest were advocated by 
Wier Mitchell. (Personal communication.) 

1 Buzzard, "British Med. Jour.," March 3, 1900. 

2 "Brain," Winter, 1905. 



PAET III. 

DISEASES OF THE BRAIN PROPER, 



CHAPTER I. 
THE CEREBRAL CORTEX— LOCALIZATION* 

General Considerations. — The subject of localization of function in 
the cerebral cortex has attained great importance and its literature vast 
proportions. The practical considerations will be briefly and somewhat 
dogmatically set forth. Many points are still under debate, aAvaiting 
further experience and experiment, and some of these problems it is 
likely will never reach solution. It is well determined that there is a 
definite area of the cortex that is closely associated with motor func- 
tions. As a working scheme we may consider that motion is represented 
in three levels : First, in the gray matter of the spinal cord ; second, in 
the Rolandic area of the cortex ; third, in the highest level of conscious 
thought, probably in the frontal region of the brain. The spinal level 
may be considered that of reflex, vegetative automatism, the Rolandic 
level that of motor combinations, and the frontal area that of conscious, 
selective, and intelligent action. Thus, destruction of the highest level 
leaves automatic action practically unimpaired, as in the experiments of 
Goltz, who removed the entire cerebrum of dogs without depriving them 
of muscular motion or bodily function. In the automatism of dementia 
the motor combinations are likewise preserved. The mid-level, the 
Rolandic region, may be destroyed, leaving consciousness of volitional 
motions and the will to execute them, but the cortical mechanism of 
their muscular production is gone, and they default, as, for instance, in 
motor aphasia. If the lowest or spinal level be destroyed, the mind 
and the memory organ have lost their tool and peripheral paralysis 
obtains. All thought contains the two ideas of motion and sensation. 
They cannot be separated, and without them consciousness is impossible. 
Indeed, they are in a certain sense identical. Motion is to the mind 
but the sensation of a change of position, and sensation is only the 
recognition of variations of motion. The flutist, by laborious conscious 
effort, establishes motor faculties in his central gyri which can subse- 

167 



168 DISEASES OF THE BRAIN PROPER. 

quently be called into operation by the will with a rapidity of which 
conscious thought is incapable. The new-born child can hardly direct 
its hand to its face, but very rapidly develops a coordinate motor con- 
trol of this act in the motor cortex that thenceforward is easily recalled 
or subconsciously repeated. In the spinal levels single muscles or groups 
of muscles are represented. In the motor cortex coordinate and func- 
tionally associated movements are located, and in the highest level 
resides their volitional control and the power to recall and select them. 

If these propositions are true in any degree, we would expect a neigh- 
boring relation of motion and sensation in the cortical representation, 
and this is no doubt the case. It is more than probable that sensation is 
represented bilaterally in the cerebral cortex more completely than unilat- 
eral motion, and is consequently less modified by one-sided cerebral dis- 
ease. 

The inharmonious views variously entertained relative to sensory 
depots in the cortex may be partially reconciled if we consider the sensori- 
motor zone as a midway station for sensation as well as motion and con- 
ceive of a higher cortical sensory level. 

The motor cortex is anatomically, or rather histologically, divided 
into from three to eight layers by various investigators. The important 
fact is brought out by all that the superficial layers are granular, and 
that the cells become progressively larger and more completely differ- 
entiated as we descend, until, in the lower strata of the motor region, 
the cells correspond in appearance to the multipolar pyramidal elements 
of the motor horns in the spinal cord. The cortical cells are practically 
all present at birth, and the development and growth of the brain 
depend mainly upon the increase in their dendritic processes and the 
fibrous feltwork that supports them. It is now generally believed that 
the interrelation of these cells is due not to actual continuity of their 
processes, but merely to their interlacing and apposition. The con- 
ditions, apparently, which best favor the transmission of nervous in- 
fluence and the functioning of nerve-cells would be close filamentous 
apposition. Withdrawal of contact might serve as an insulating and 
inhibiting measure, a theory strongly supported in some quarters, but 
as yet only a theory. The nuclei of these cells are now considered as 
only dominating their nutrition, and not otherwise essential to their 
activity, which is relatively the same at the dendritic periphery as in 
the cell-body. 

Movements dependent upon paired muscles, such as those of the 
trunk, are rarely abolished by unilateral brain disease. Those of a 
specialized and one-sided character, however, may be completely inhib- 
ited by unilateral disease of their cortical centers. Thus, the frontalis is 
rarely affected in cortical hemiplegia, while the unilaterally acting mus- 
cles of the lower part of the face are usually paretic in this condition. 
It is an acceptable proposition that all skeletal muscular activity is bi- 
laterally represented, and it is also true that all unpaired muscles and 
their coordinate activities are more particularly controlled by the oppo- 
site half-brain. The acquired faculty of speech, however, and the nu- 
merous motor and sensory functions associated with it, are almost always 



THE CEREBRAL CORTEX— LOCALIZATION. 



169 



mainly represented in the left cortex in right-handed individuals. The 
superior weight and development of the left half-brain is probably 
largely attributable to its better nutritive supply through the arrangement 
of the vessels at the aortic arch and the larger caliber of the left carotid. 
This induces right-handedness, which in time, no doubt, retroactively in- 
creases the functional activity of the left cortex. At the same time 
the left hemisphere becomes potentially greater, more acquisitive, and 
therefore largely the seat of acquired motor and sensory education, which 
in turn increases its growth. It is probable that some overflow occurs 




AL__ 



Fig. 66.— Scheme to represent the cortical arterial circulation, a p m, Artery of the pia mater; 
A c, short arteries to the gray matter only; a l, long arteries penetrating the white substance (after 
Brissaud). 



in most brains, so that automatic, emotional and expletive expressions 
either come to be located in the right brain or their frequent repetition 
sufficiently educates the right cortex to enable them to be recalled 
through its agency when the left centers are cut off. Similarly, if speech 
control be lost to the left half-brain, the right, especially in young per- 
sons, may be in turn educated to take its place in large measure. It is 
worthy of consideration whether the whole conscious and unconscious 
tendency of education, habit, custom, and practice to make all men right- 
handed is not a serious mistake. It seems plausible that should left- 
handedness, or rather ambidexterity, be assiduously cultivated in chil- 
dren, the two hemispheres of the brain might enjoy a greater equality 
and the individual secure not only amplified muscular control, but a 
certain lessened liability to aphasia and hemiplegic losses. 

Motor Cortical Localization. — The human cerebral motor cortex 
has been mapped out with fair uniformity by numerous investigators. 
Following the lines laid down by Ferrier, Schaefer, and Horsley, 
originally based upon experiments on the monkey, the results of focal 
lesions in man and actual stimulation of the human cortex by electricity 
have given a fair degree of precision to the outlines of the motor area. 
Comparing figures 67 and 68, we may see that all skeletal-muscle groups 



170 



DISEASES OF THE BRAIN PROPER. 



are represented. Such outlines must be taken as suggestive rather than 
actual. There is no sharp boundary between the adjoining centers, and 
these fields overlap. The dippings of the sulci also serve to interfere 
with sharp limitations of the cortical areas and obstruct the experimental 
stimulation of individual movements. Every muscular movement, ap- 
parently, has a locus of principal or major representation in the cortex, 
but such a movement is so wrapped up Avith other coordinate movements, 
and so widely related functionally, that its representation in a minor de- 
gree may spread over great areas. The thumb, for instance, is princi- 
pally represented in a given small cortical center, but the prehensile 
action of the thumb is related to the grasp of the fingers, the fixation 
of the wrist, the rigidity of the whole upper extremity, and even to 
action of the trunk and lower limbs in strongest efforts, during which 
the opposite members also come into play. 




Fig. 67.— Functional areas of the cerebral cortex of the left side (after Campbell). 



The most recent investigation of cortical localization in anthropoids 
by Sherrington and Griinbaum, and the histological studies of A. W. 
Campbell, 1 indicate that the true motor region of the cortex is much less 
extensive than was formerly thought. The functional groups of skeletal 
muscles are represented in the precentral or ascending frontal convolu- 
tion from the lower end of Rolando's fissure up to the midline of the brain, 
and to a slight extent on the mesial surface of the hemisphere, in a con- 
tinuous narrow zone. The bottom of the fissure of Rolando sharply 
bounds the motor area behind, and it extends forward not to exceed the 
width of the precentral gyre. 

Liepman 2 and Wilson 3 have shown conclusively that the ability to 
perform skilled movements with the limbs resides in the first and second 

1 "Histological Studies of the Localization of Cerebral Functions," 1905. 

2 " Monatsschr. f. Psychiatr. u. Neurol.," 1900, 1906, 1907. 

3 " Brain," 1908. 



THE CEREBRAL CORTEX— LOCALIZATION. 



171 



convolutions of the left side. Their destruction results in a loss of such 
motions, a condition called ajpraxia, analogous to or identical with 
motor aphasia and agraphia. This state may be unattended by any 
evidence of paralysis. 




Fig. 68. — Functional areas of the mesial surface of the left hemisphere (after Campbell). 

At the branching of the fissure of Sylvius motious of the tongue and 
platysma are represented, and immediately above them the muscles of 
the face — first the lower, then the upper, face parts. Next in order we 




Fig. 69.— Relations of body to cortical areas. 



encounter finger, ivrist, elbow, and shoulder movements ; then those of the 
trunk, and highest of all those of the lower extremity, which lap over the 
mesial margin of the hemisphere. 



172 DISEASES OF THE BRAIN PROPER. 

In front of the centers for the tongue and mouth parts, in Broca's 
convolution, the third left frontal, motor vocal speech, is principally rep- 
resented. In left-handed individuals this motor function is located on 
the right side of the brain. 

If we take the Rolandic area, from the superior margin of the half- 
brain to the Sylvian fissure, and divide it into fifths by horizontal parallel 
lines, the face occupies the lowest two-fifths, the upper extremity the 
next two-fifths, and the trunk and lower extremity the highest and re- 
maining fifth. 

Sensory Cortical Localization.— The impossibility of accurately de- 
termining sensory disturbances in animals is one of the major reasons for the 
confusion that exists regarding the cortical representation of this function. 
Now that the unipolar method of stimulation is being adopted and the 
comparative insensitiveness of the brain has been proven we may expect 
definite records on many points of cortical function through observation on 
the human cortex of conscious subjects. The postcentral convolution, 
according to Campbell, and a large portion of the parietal area, present the 
histology of sensory cortical structures. There is a large mass of clinical 
observations to indicate that this portion of the cortex has sensory func- 
tion, though Bergmark x is disposed to limit it solely to the post-central 
convolution. Stereognosis, a complicated sensory function, is located in 
this region, and backward and below in the region of the angular gvre 
of the parietal lobe on the left side we confidently locate the cortical 
representation of visual functions. 

Vision. — The optic radiations arising from the outer geniculate body 
and in the neighborhood of the quadrigemina stream backward into the 
occipital lobe and reach the cortex at its apex. It may now be accepted 
that half-vision is represented at this location, — namely, — that the cor- 
responding half of each retina is subserved by the occipital cortex of the 
same side (see Fig. 29). The investigations of Henschen and others 
indicate that the macula is represented in each occipital cortex in more 
or less complete degree. It thus results that ablation or destruction of 
one occipital lobe produces double homonymous hemianopsia. In this 
condition the macula is regularly spared, as it is sufficiently supplied by 
the opposite lobe. It is likely that the half-retina may be further 
divided into irregular and varying upper and lower quadrants, with 
localized cortical representation. It is indicated by some clinical cases 
that the fibers in the optic radiation which serve the upper quadrants 
are above those for the lower, and that the macular fibers are placed be- 
tween them. Altogether they make a bundle about a centimeter thick, 
passing horizontally backward at the level of the second temporosphe- 
noidal gyre. They finally reach the apical occipital cortex, and seem to 
have their maximum field in the neighborhood of the calcarine fissure on 
the mesial surface of the lobe, over all of which half-vision is repre- 
sented to some extent. 

Higher visual coordinating and combining centers no doubt exist, 
and probably are in the angular gyre of the parietal lobe, where Ferrier 
first placed vision. Functions related to printed speech are probably 

i" Brain," 1910. 



THE CEREBRAL CORTEX— LOCALIZATION. 173 

located here in particular and on the left side alone. Destruction of the 
left angular gyre, therefore, produces word-blindness, and destruction of 
both angular gyri produces mind-blindness, all objects failing recognition. 

Hearing is subserved by the first and slightly by the second tem- 
poral convolutions, which are in relation with both ears. It, therefore, 
requires bilateral destruction of the gyri to produce complete cerebral 
deafness. Functions related to the reception of spoken words are 
apparently represented in the posterior two-thirds of the first and second 
temporal gyri on the left side. When this area is destroyed, the right- 
handed patient becomes word-deaf. 

Smell and taste are presumably located in the cortex of the median 
surface of the temporal lobe, smell in the uncinate convolution, and taste 
below it in the fourth temporal. Broca, and after him Zuckerkandl, 
located smell throughout the limbic lobe, but Ferrier and later investi- 
gators are disposed to confine it to the uncinate gyre and the hippocampal 
region. The recorded cases bearing upon the locations of smell and taste 
are extremely few and not convincing. The region is not often affected 
by limited lesions. A few hemiplegics lose smell in the nostril opposite 
a lesion which involves the temporal lobe. Lesions of the tip of the 
temporal lobe have also been found in epileptics who had a gustatory 
aura or one of smell. Insane hallucinations of smell have been related 
to disease in this portion of the brain. 

Cortex of Unknown Function. — Examination of the diagrams 
(Figs. 67, 68) will at once indicate that the cortex of unknown function is 
much greater on the right than on the left side, owing to the fact that speech 
finds its .representation almost solely in the left brain. In the frontal 
area, anterior to the motor zone, it is customary to locate the higher psy- 
chical functions. While it is true that this region may be largely de- 
stroyed by injury or disease without producing localizing symptoms, 
there is a rapidly growing number of cases indicating that mental and 
moral obliquities are usually the sequence of such lesions. Ablation of 
the prefrontal region in dogs and monkeys induces a change of charac- 
ter, of disposition, of behavior, that is clearly recognizable. In men 
with prefrontal brain injury, mental sluggishness, want of attention, 
diminished memory, loss of energy and of self-control, are noted with 
more than coincidental frequency. The upper and posterior parietal 
regions, a portion of the temporal cortex, and the island of Reil are 
still unaccounted for. These are known as regions of latent lesions — 
of lesions which do not necessarily produce symptoms. 

Craniocerebral Topography. — It is very necessary in many cases 
of brain disease to locate the underlying cortex, either for the purpose 
of operation or to determine the relation of scalp wounds, depressed 
fractures, and other traumata, to the cortex. No brain presents sym- 
metrical hemispheres, consequently we can not expect a close resem- 
blance between the brains of different individuals. There are also 
variations for sex, age, and body-weight. Very often there are super- 
numerary or unusual convolutions on one or both sides. A number of 
methods have been devised by Reid, Horsley, Hare, and others, to map 
out on the scalp the underlying cortical areas. They all have valuable 



174 



DISEASES OF THE BE A IN PROPER. 



features; but if you apply a number of them to the same head, so im- 
portant a landmark as the Sylvian fissure will be variously defined. 
Absolute exactness, for the reasons already indicated, is not within the 
range of possibility. With the formulas named, the difficulty lies largely 
in selecting rather indefinite anatomical points, like the parietal boss or 
the temporal ridge, and making measurements in inches or other units 
from these points on ill-defined lines or angles. A simpler and proba- 
bly more accurate plan is advocated by Drs. Anderson and Makins, of 



*=r-M$P 








Fig. 70. — Craniocerebral guiding lines traced upon a cast of Professor Cunningham's (from a photo- 
graph). GP, Glabellar point, glabella opposite superior border of orbit; IP, inial point, at external 
occipital protuberance; MSP, mid-sagittal point, midway between GP and IP; Ang.P, angular point, 
external angular process opposite upper border of orbit ; Sq.P, squamosal point, intersection of oblique 
and frontal lines at junction of middle and lower thirds of latter; PP, parietal point, termination of 
oblique line, equidistant with FS 2 from squamosal point ; Aur.P, pre-auricular point, depression in 
front of tragus, at the level of upper border of external auditory meatus; FS 1 , "commencement" of 
fissure of Sylvius, five-twelfths of distance from Ang.P to Sq.P ; FS 2 , bifurcation of fissure of Sylvius, 
seven-twelfths of distance from Ang.P to Sq.P; FS 3 , termination of fissure of Sylvius, % of an inch 
above PP, in a direction parallel to frontal line; FR 1 , upper extremity of fissure of Rolando carried to 
sagittal line in direction of fissure, % of an inch behind mid-sagittal point; FR 2 , lower extremity of 
fissure of Rolando carried to oblique line in direction of fissure, % of an inch in front of squamosal 
point ; PO. external parieto-occipital fissure carried to sagittal line in direction of fissure, seven-twelfths 
of distance from MSP to IP. 



London, based upon a series of forty observations upon adult male and 
female heads and the heads of children. The system depends upon 
averages and proportions, making it of wider application than the 
others. It has served the writer well in many cases. 

First a line, the sagittal line, is drawn in the median plane from the 
glabellar point to the external occipital protuberance. The glabellar 
point is determined by drawing a horizontal line at the level of the 
upper border of the orbital openings, and marking its intersection with 
the median plane. It corresponds very nearly to the union between 
the nasal and frontal bones. At exactly one-half the length of this line 
is marked a vertical point. Seven-twelfths of the distance from the 
vertical point to the external occipital protuberance, which can always 
be readily located, is a point corresponding to the parieto-occipital 
fissure, marking the limits of the parietal and occipital lobes. From 
the depressions immediately in front of the tragus of each ear, at the 
level of the upper margin of the external auditory meatus, lines called 



THE CEREBRAL CORTEX— LOCALIZATION. 175 

frontal lines are drawn to the vertical point already mentioned. At the 
junction of the middle and lower thirds of the frontal line lies the fis- 
sure of Sylvius, and this point, corresponding fairly well to the squamous 
suture of the temporal bone, is called the squamosal point. From the 
squamosal point a line, the oblique line, is drawn downward and forward 
to the external angular process of the frontal bone, at the upper orbital 
border level, as in fixing the glabellar point. Divide this line into 
twelfths. Five-twelfths of the distance from the angular point to the 
squamosal point begins the fissure of Sylvius ; at seven-twelfths it bifur- 
cates and extends by its horizontal line backward under the oblique line, 
and in its continuation to a distance posterior to the squamosal point equal 
to the distance of the point of bifurcation anterior to this intersection 
of oblique and frontal lines. At the termination of the oblique line 
the Sylvian fissure turns upward about J of an inch parallel to the 
frontal line, to terminate approximately under the parietal boss. To 
mark the fissure of Rolando, draw a line from the sagittal line f of 
an inch posterior to the vertical point downward and forward, at an 
angle of about sixty-seven degrees, to terminate f of an inch anterior 
to the squamosal point on the oblique line. The fissure of Rolando 
lies under this line, but terminates, as a rule, j of an inch above the 
Sylvian, though very rarely opening into it. 

Having thus fixed these two important and tolerably uniform fis- 
sures, the marking off of the principal convolutions is simple. Owing 
to the fact that there is no absolute relation between the cranium 
and the convolutions, it is necessary, when they are exposed, to verify 
them, if they are motor in character, by the application of the faradic 
current. This is done by means of a wire pointed electrode, and may be ac- 
complished even through the unopened dura. The exact localization of 
the gyri before the skull is opened is less important when a large bone flap 
is made, as now commonly is done. 



176 



DISEASES OF THE BRAIN PROPER. 



CHAPTER II. 

SPEECH AND THE CORTEX— APHASIA. 

General Conditions. — A word has four principal cerebral qualities : 
it can be heard and seen, and it can be spoken and written. The first 
two are afferent qualities of perception. The second two are efferent 
qualities of expression. We, therefore, have four groups of word func- 
tions : (1) Those of sound, or auditory ; (2) those of sight, or visual; 
(3) those of the motions necessary to express words in speech, vocal 
motor, and (4) probably those of the motions required to express them 
by written symbols, graphic motor. For these four groups we have 
four cortical areas, as indicated in Fig. 71, p. 176, where these word 
characteristics are principally represented. The speech area of the brain 
is an extensive one, and the faculty of speech in its various qualities is 
subserved by it in a general or common manner. The elements of 
motor or expressive speech, that is, vocal utterance, writing, and motor 
signs and gestures, pertain more to the anterior section of the speech 
zone, namely, in front of the fissure of Eolando. The elements of sen- 
sory or receptive speech are mainly represented in the posterior portion 




Fig. 71.— Speech areas in the cortex. A, Auditory ; B, motor vocal speech ; C, visual speech, 
including written characters and lip positions ; D, graphic motor speech (after Wyllie). 



of the speech area. These word-centers are brought into mutual rela- 
tions by systems of connecting fibers and into relation with their corre- 
sponding receptive and emissive peripheral organs by afferent and effer- 
ent tracts. AYe may indicate these connections by a diagram (Fig. 72). 
Thus, take the word apple ; when it is spoken we hear it through the 
temporal lobe, and when written, we see it through the angular gyre of 
the parietal lobe. AVe call up combinations of muscular movements in 
the third left frontal gyre when we would utter it vocally, and those 
probably in the neighborhood of the hand-center when we would ex- 
press it by writing. At the present time the arbitrary and even par- 
tially theoretic division of the cortex into areas and depots for the 



SPEECH AND THE CORTEX— APHASIA. 



177 



various verbal functions has undergone much modification as a result 
of the critical review begun by Marie, 1 who, indeed, denies all speech 
qualities to the third frontal or Broca's convolution. It seems prob- 
ably true that all the cortex and subcortex associated with speech may 
be affected by a lesion in any part of it. Such lesions produce a general 
reduction of speech power which takes on various phases, depending to 
some extent on the location and extent of the lesion or lesions, and 
numerous variations are determined by the personal characteristics of 
the patient and the lapse of time. 

Schematically, we may say that as one or another of these major 
speech-centers is diseased we have corresponding varieties of cortical 
speech defect, or aphasia. They are : (1) Auditory aphasia, or word- 
deafness ; (2) visual aphasia, or word-blindness ; (3) motor aphasia, or 
aphemia, and (4) graphic motor aphasia, or agraphia. Disturbance of 
the connecting fibers also disturbs speech, giving rise to a number of 
secondary or connectiny aphasias. Again, more than one center may be 
simultaneously affected, causing combined aphasias. The four primary 




Fig. 72.— Diagram showing receptive and emissive speech-route, and the primary interrela- 
tions of the major cortical representations for speech. A, B, C, D, correspond to the cortical parts 
similarly indicated in the preceding figure (after Wyllie). 

so-called word-centers are, to a large degree, mutually dependent. "Word- 
blindness is often attended by agraphia, as the mind is unable to recall 
the visual image of the word, which is to be copied, as it were, through 
the action of the graphic center. Again, if there is word-deafness, the 
patient cannot write to dictation, though he may copy perfectly. 

Individuals vary greatly in the quality of their verbal faculties. As 
first emphasized by Charcot, one may have his words principally asso- 
ciated with the auditory area (auditif), another with the motor area 
(moteur), and a third with the visual area. If we learn a new language 
by ear its memories are mainly auditory, and if by the book, they are 
visual. It is only when we have acquired oral proficiency that our 
motor faculties are fully established and may finally, perhaps, predomi- 
nate. Probably only those who constantly express themselves in writ- 
ing for many years so fully establish the graphic motor functions that 
they become relatively independent of the other word-centers. It follows 
that children always have auditory word memories first developed, the 
motor or verbal expression following. The visual and graphic memories 

*"Sem. med.," 1906, 1907. 



178 DISEASES OF THE BRAIN PROPER. 

then in turn are acquired. From these considerations we can under- 
stand how it is that apparently identical lesions rnay produce results 
differing in degree in different cases. 

The stability of word faculties depends upon the intensity with which 
they are imprinted upon the convolutions, either by some special em- 
phasis or by frequent use and repetition. Thus, words as well as inci- 
dents that come with the shock, for instance, of fright, are always readily 
recalled. Every one knows the value of repetition in fixing a point in 
the student's mind. Nouns, being least frequently used, are the most 
easily displaced, and proper nouns suffer the earliest of all. Verbs, 
adjectives, adverbs, and prepositions follow in a methodical order, gov- 
erned by the rule of depth of imprint due to repetition in daily use. 
This necessarily varies with the individual. An oft- repeated oath, 
"yes," and "no" are the most persistent of all. 

It sometimes happens that the word or phrase on the patient's lips, 
at the moment of the stroke producing the aphasia, remains his only vocal 
expression. This he repeats at every attempt to speak, being, as it were, 
saturated or intoxicated with it. It has been suggested that its imprint 
under the circumstances of the stroke has made it indelible. In writing, 
the aphasic condition is often indicated by the repetition of letters or 
words. The name is usually signed promptly, if the patient has been 
accustomed to the act, which tends in time to become automatic. Some- 
times only the first few letters of a word are accomplished, and then 
repeated again and again, or words are repeated. The tendency to 
echolalia is also very noticeable, the patient repeating some word or ex- 
pression he has himself uttered or just heard others employ. 

In many cases of aphasia the patient miscalls objects or uses wrong 
words, especially names and personal pronouns. This is denominated 
paraphasia, and is most marked in lesions of the auditory word memory 
depot. In this case the patient does not make persistent attempts to cor- 
rect himself, as he is unable to recognize his own mistakes. When the 
auditory centers are not primarily involved paraphasia is recognized by 
the patient, who constantly manifests his annoyance at being unable to 
utter the proper word. 

The mental capacity of aphasics varies greatly, and must be carefully 
estimated in a given case. As a rule, it is somewhat modified, as is 
clearly indicated by the changed temperament and disposition practically 
always present, even in the slightest cases. The organic mischief pro- 
ducing the cortical lesion may induce complete dementia, and in any 
event the mind works somewhat clumsily. According to Bastian and 
others the sensory forms of aphasia, those mainly marked by auditory 
and visual disturbance, are more likely to present mental deterioration 
and to develop insanity than the motor varieties. In such cases hallu- 
cinations of sight and hearing, due to irritation of the cortex, are not 
infrequent. Even in cases of slight degree, as Marie has well insisted, 
there is a certain level of complexity of mental operations beyond which 
the patient cannot go. As ideation depends so intimately on word proc- 
esses, the reduction of the cerebral speech faculties in any manner 
necessarily impairs the flow of thought. 

Besides the loss of visual word processes, the patient is unlikelv to 



SPEECH AND THE CORTEX— APHASIA. 179 

recall figures, algebraic or other conventional signs, and musical nota- 
tion. Mind-blindness, in which all objects are unrecognized, is due to 
a bilateral lesion of the word-visual cortex. In some cases of auditory 
aphasia the patient has shown a loss of musical appreciation, a condition 
termed amusia, and, as far as music is an acquired educated faculty, 
it is presumably associated with the left temporal lobe. Most motor 
aphasics whistle or hum tunes with more or less precision, and cases 
are on record in which motor speech was lost, but the patient could sing 
the words of a song correctly. One case replied "God damn" to every 
question, but got out most of the words of "Annie Rooney" with dis- 
tinctness when he attempted to sing. Such cases demonstrate con- 
clusively that word memories are not destroyed, but there is a gen- 
eral reduction of the speech faculty which, assisted by the crutches of 
rhythm and music, still functionates. 

Secondary means of expression, such as pantomime, facial expression, 
aDd gestures, are usually retained, but in rare cases the patient neither 
correctly produces nor understands them. This may go to the extent 
of nodding the head when negation is intended. The loss of gesture and 
mimicry is called amimia ; their misuse is paramimia. Both these are 
manifestations of apraxia. Emotional facial expression is generally re- 
tained, so that when the mind is not too much impaired the feelings of 
the patient are vividly portrayed in his countenance. There is some 
reason to locate these expressional centers in the basal ganglia, especially 
in the optic thalamus. 

The motor cortex subserving speech is all within the domain of the 
middle cerebral artery, and aphasia is most frequently due to diseases of 
the branches or the trunk of this vessel. Trauma, meningkic disease, 
and new growths may also cause it. The most common simple variety 
of aphasia is the motor form, next the auditory, and then the visual. 
Distinct cases of graphic motor aphasia are extremely rare, but a con- 
vincing instance has been recorded. A combination of motor aphasia 
with the auditory and visual varieties is that ordinarily encountered. In 
this connection the various speech areas may be affected in different 
degree. Variations due to improvement or failure in the various speech 
qualities in any given case furnish constant study. The initial con- 
ditions are usually exaggerated by the participation of surrounding brain 
areas in the field of cerebral insult. After a few weeks or months, 
through education of the opposite cortex and partial local recovery, the 
clinical picture may be entirely altered. 

Before taking up the various schematic forms of aphasia the reader 
is referred to the methods of examination in such cases described in 
Part I, p. 69. It may be well to call attention to the fact that the 
blind read type with their fingers, and that the deaf, by lip reading, 
cultivate special verbal processes, which must be specially localized in 
the cortex. We must also bear in mind that the word and the object 
are not the same, but that one is the symbol, sign, or name of the other. 
The word-percept is, therefore, distinct from the object-percept, which 
is a part of the higher intelligence. It follows that the aphasic can 
mentally recall the object, as a chair, though he cannot name it. The 



180 DISEASES OF THE BRAIN PROPER. 

object-percept may also be called up by various routes besides those of 
hearing and seeing. By smell, or touch, or taste alone we can recognize 
familiar quantities that have corresponding qualities, and at once the 
word or name springs to the lips. The object-percept is, therefore, 
made up of and embraces all the attributes of the given object with 
which the individual is definitely acquainted. 

Auditory Aphasia. — The lesion is in the left temporal lobe. The 
most striking condition is the word-deafness. The patient gets only a 
partial suggestion of what is spoken to him, or fails completely. When 
the intellect is fairly clear he is likely to make good guesses from the 
circumstances of the interview, the examiner's gestures, intonation, ex- 
pression, or the motion of his lips. These sources of suggestion must 
be guarded in making tests. Usually, the visual speech-center, from its 
near location, suffers with the auditory, so that alexia is added, but if it 
escapes, the patient may read understandingly. 

As most people are strongly auditif, the destruction of their auditory 
word memories notably impairs the emission of vocalized words. This 
manifests itself in paraphasia, and the speech may be reduced to a jargon 
or gibberish, which the patient expresses in a well-modulated way, and 
with an intelligent appearance. He does not recognize his own mistakes 
because of the word-deafness. He is likely to coin words and to repeat 
syllable sounds. Frequently he starts a word properly and then muti- 
lates it. In trying to describe his feelings, such a patient said, with 
gestures to his head and abdomen, " I have a sulitar pretty well dear 
swell manoeuver, and there are fullis things that hang solidar. There is 
a clean, fleshurable, pleasurable, fair, unsurizable, and any surizable way 
for a good deal insurations that is rotality all the time." He was 
annoyed that others could not understand him, and that he could not 
fully understand others. Very rarely would he attempt to correct a 
word. The writing of such a patient shows the same thing as his vocal 
utterances, both indicating the loss of the auditory speech memories upon 
which the majority of mankind are mainly dependent. He, therefore, 
uses wrong words, repeats words or letters, or his attempts lose all 
semblance to written speech. The ability to repeat words from dicta- 
tion, or to echo sounds, may be destroyed, and is always greatly im- 
paired. Copying written or printed characters is not affected. Amusia 
may be present. The mental reduction is always pronounced. 

Motor Aphasia, or Aphemia. — The lesion is in the foot of the 
third left frontal convolution, but usually extends to the foot of the 
ascending frontal, giving rise at the same time to motor difficulties in 
the lips and tongue. A subcortical lesion has all the significance of 
one purely cortical, or even more so, as a purely cortical lesion of the 
third frontal, producing motor aphasia, is by some entirely denied. A 
single case by Dejerine can be adduced. The characteristic condition 
in marked cases at first is the inability to produce articulate speech. 
Remnants like yes and no, or expletives, or an occasional habitual word 
may be retained, represented, as it is supposed, through the overflow 
into the right half-brain which occurs in the process of cortical educa- 
tion. As the right side is further educated, or if partial recovery in 



SPEECH AND THE CORTEX— APHASIA. 



181 



the left side ensues, the vocabulary increases. In the young the edu- 
cation of the right convolutions goes on with considerable rapidity if 
the mental impairment is slight. In recovering and in partial cases 
attempts at articulate vocal expression partially fail, from the loss of 
the verbal motor combinations. In severe cases the condition is abso- 
lute, complete aphasia. Motor aphasics sometimes misuse nouns (par- 
aphasia), and they at once recognize their errors. They frequently 
paraphrase to get around their naming defect, as, for instance, " Give 
me some of that stuff for the bread," meaning butter. Wyllie also calls 
attention to the infantile characters of the speech in improving motor 
aphasia, such as lisping, lalling, and the cutting off of terminals and ini- 
tial syllables. They cannot repeat dictation any better than they can 
speak spontaneously. As a rule, agraphia is present and proportionate 
to the motor aphasia. For this a number of reasons are assigned. 




u^U-^£L^^£<7\^ 




Figs. 73, 74. — Handwriting in a case of motor apbasia. Patient's attempt to write his own name — Geo. 
W. Whitehall: A, spontaneously; B, after dictation. 



Usually there is right hemiplegia, and the right hand is powerless. 
When the hand is not disabled, the agraphia persists none the less. It 
will be recalled that the graphic motor word memories are last acquired, 
the least deeply imprinted, and probably very easily disarranged. They 
are, no doubt, closely associated with the motor vocal memories, not 
only by nearness of location, but in function. As one learns to write, 
and even after much usage of the pen, he unconsciously inwardly pro- 
nounces first the letters singly and later the syllable sounds as he exe- 
cutes the written characters. Agraphia is really apraxia, and probably 
due to the participation of the prerolandic area of the second frontal 
gyre. A few rare cases of motor aphasia have retained fairly good use 
of written speech. It may be that the individuals possessing deeply 
imprinted auditory, visual, and graphic-motor word memories would be 
less affected than the usual auditif-moteur class. In attempts at writing, 



182 DISEASES OF THE BRAIN PROPER. 

motor aphasics frequently repeat a word or letter, or write only the few 
words of which they are vocally capable. Their narnes are usually 
signed with readiness if they can guide the hand. The motor aphasic 
who is able to use his right hand can copy readily and accurately, though 
he usually is unable to read. Even with the left hand they can copy 
as well as another. From dictation their efforts are no better than in 
spontaneous attempts. The motor aphasic understands all he hears and 
obeys commands unless too complex. There is no word-deafness. 

Reading is notably impaired and in the same degree as writing. 
The association of visual speech with motor speech is a close one. All 
in learning to read pronounce as they go along, and even in after-life, 
when one is reading carefully, the tongue will be found slightly moving 
in the mouth in the same manner that the words would require were 
they pronounced. Yet many of these patients will intently scan the 
papers for hours or apparently read and reread the same books and in- 
sist that they understand what they read. They almost invariably rec- 
ognize their own names, and in some cases seem to get the " drift " of 
what they read. 

Motor aphasics showing a high degree of verbal difficulty are the 
ones in whom amimia and paramimia (apraxia) are usually observed. 
Occasionally they cannot voluntarily protrude the tongue. 

Visual Aphasia. — A lesion destroying the angular gyre on the left 
side produces the peculiar defect of visual aphasia, or word-blindness. 



ANG.Gyr 




Fig. 75. — A lesion (X) divides the optic radiations within the occipital lobe, producing hemianopsia and 
word-blindness at once (Dejerine). 

If this lesion extends deeply enough to involve the optic radiations 
streaming from the basal ganglia to the occipital cortex, hemianopsia is 
added. A lesion in the optic radiation within the white matter of the 
occipital lobe may involve the connecting tracts between the half-vision 
centers in the apex and the higher visual centers in the angular gyre, 
producing both hemianopsia and word-blindness. It thus appears that 
word-blindness is due to disturbance of the angular gyre alone, and that 
associated hemianopsia is present only when the lesion implicates the 
optic radiation (see Fig. 75). 

The visual aphasic can see perfectly anything put before him, but 
written symbols, figures, and other conventional signs have entirely lost 



SPEECH AND THE CORTEX— APHASIA. 183 

their significance. That he sees them clearly is shown by the fact that 
he can copy or draw them with as much precision as ever. Spontaneous 
writing, however, is lacking. Not being able to call up the visual 
images of written speech, he is unable to exteriorize them through the 
motor writing apparatus, excepting in the case of some automatic com- 
binations, such as his signature. For similar reasons he cannot write 
from dictation. The hemianopsic cases, without cortical or subcortical 
parietal lesions, write spontaneously and from dictation with ordinary 
facility, as in these cases the visual word memories are not necessarily 
destroyed, but only cut off from the lower half-vision cortex in the occip- 
ital apex. They are unable, however, to read what they have written. 
Spoken language is both understood and expressed with complete readi- 
ness. When familiar objects are not recognized, miud-blindness is 
present and the lesion is probably bilateral. It appears that ordinary 
visual sensations, as sensation in general, are symmetrically represented. 
The educated faculty of visual word memories is represented in the left 
angular gyre alone. 

Graphic-motor Aphasia. — Regarding this variety of aphasia there 
has been much dispute and uncertainty. According to some, Wernicke 
in particular, the act of writing is but the act of tracing the visual word 
memories. He points out that this can be done with the left hand, the 
elbow, the foot, or even with a pencil held between the teeth. Exner 
maintains that there is a graphic-motor center in the foot of the second 
frontal convolution adjoining the centers for the hand, but this is 
not sufficiently verified. The case reported by Gordinier, 1 however, 
is very convincing. In this instance the circumscribed lesion, a 
small new growth, was located in the foot of the left second frontal 
convolution. The facility with which the right is used as com- 
pared with the left hand, or the other portions of the body, indicates that 
it has attained a proficiency quite its own, which must be resident in 
or near its principal cortical representation. Some persons write with 
small finger movements, others with a wide, full arm-sweep, the pen 
being simply grasped with the hand, which is largely guided from the 
shoulder. An ambidexter uses either hand. Their cortical writing 
apparatus must vary correspondingly. In persons deprived of both 
hands, who write with the foot, quite another cortical area must be 
educated for the purpose. It seems probable that in every case this 
education would fall upon the corresponding motor cortex, which de- 
velops specially intimate relations with the area of visual speech. Even 
this relation is not absolutely required, as the blind accurately repro- 
duce the letter forms they have learned by the sense of touch. 

It seems unnecessary to presume the existence of a higher graphic- 
motor center. Agraphia, like motor aphasia, is -a variety of apraxia, 
and is due in all probability to the involvement of the second frontal 
convolution. Agraphia is common in motor and rare in auditory 
aphasia. In auditory aphasia we more commonly have paragraphia, 
unless the lesion also involves the visual speech-cortex. 

Conduction Aphasias. — The aphasias thus far considered are due to 
1 " Am. Jour. Med. Sci., " May, 1899 ; ibid., Sept., 1903. 



184 DISEASES OF THE BRAIN PROPER. 

lesions affecting more or less definite cortical functions. There are others 
due to lesions of the conducting tracts that bring these cortical areas of 
major functional speech representation into mutual and coordinate rela- 
tions. The most important is the one produced by breaking the path 
between the auditory and motor word-centers. This is usually due to a 
lesion of or in the neighborhood of the island of Rett. It was first de- 
scribed by Wernicke, and is sometimes called Wernicke's conduction 
aphasia. These patients present no particular auditory or articulative 
difficulty, but, owing to the loss of correlation between auditory and 
motor elements, they lose selective ability when they try to express 
themselves, and a most marked paraphasia and paragraphia result. 
They are obedient to direction, but cannot repeat dictation orally or in 
writing, though they copy with perfect precision. Neither can they 
read or pronounce aloud, though they seem to read understandingly. 
There is very little attempt to correct errors of spoken or written 
speech. The writer has seen such a case, due to traumatic hemorrhage, 
which was relieved by operation, the clot being found under the oper- 
culum, on the surface of the insular convolutions, where it had been 
located from the symptoms. The recovered patient now states that 
there was considerable mental confusion during the aphasia, to which 
the verbal disturbance no doubt would conduce. 

Wernicke, Lichtheim, W T yllie, and others describe four other more 
or less theoretical varieties of conduction aphasia depending upon the 
location of the lesion in relation to the conducting tracts to and from 
the auditory and motor fields. Some quoted cases also are given in 
their support. 

Combined Aphasias. — It has been pointed out that all word repre- 
sentation is in the arterial territory of the middle cerebral. Conse- 
quently from this source, as well as by trauma, meningitis, or cerebritis, 
they may all be thrown out at once. Simultaneous injury to the audi- 
tory and visual word functions is comparatively frequent, and it has 
been seen that graphic-motor activities usually disappear with the vocal 
motor — a combination due not only to association in function, but to 
proximity and to the attending apraxia. The loss of auditory and 
motor memories practically entails a loss of all speech attributes, as the 
visual and graphic-motor features are so thoroughly dependent upon 
them. Again, the centers may be unequally affected, so that sensory 
disturbance preponderates over motor, or the contrary. The type cases 
indicated in the foregoing pages are indeed rare, but by their description 
we can unravel the combined forms. 

The mental disturbance is usually proportionate to the speech defect, 
and in total aphasia is very marked. 

Reeducation of Aphasics. — One of the most important questions 
in a given case of aphasia regards recovery from the speech defect. Pure 
motor aphasia is perhaps the most hopeful variety in this respect, as 
verbal motor activities are the most easily built up. Reading usually 
follows much more slowly and writing is even more tardy. The forms 
of aphasia connected with the loss of sensory word attributes are the 
most persistent. As often mentioned, a majority of persons are auditif, 



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186 DISEASES OF THE BRAIN PROPER. 

and all are necessarily so in childhood, though the child intently watches 
the lips of those teaching it to speak and probably acquires visual 
memories in- association with the auditory impressions. In the sensory 
aphasias the mental disturbance is usually greatest. The loss of these 
earliest and usually most deeply graven memories, which become domi- 
nant in the speech mechanism, is the most difficult to overcome. 

The first step is to determine by which route the intelligence may 
best be reached. Even when both auditory and visual memories are 
gone, some patients can use the sense of touch to good advantage, and 
it will often be found an aid to put familiar objects into their hands 
when encouraging them to name them. If they are capable of giving 
attention, much may be expected. Simple sounds, such as a child 
first utters, like ba, pa, ma, may be indicated to them and repeated by 
the voice and in writing, by the position of the lips, mouth, and tongue 
of the instructor, or by taking the patient's hand and tracing the letters 
either in air or on a blackboard. If some object can be used, — say, a 
knife or pen, — it should be kept before the patient and placed in his hand 
when he attempts to name it. When simple sounds are mastered they 
can then be grouped into words, and the words associated with objects 
or actions, and so a vocabulary built up, which must be frequently and 
repeatedly and patiently rehearsed. By unremitting, intelligent effort, 
some emissive speech may be taught almost every case. It adds greatly 
to their comfort and makes their care less burdensome. 



CHAPTER III. 

THE CEREBRAL WHITE MATTER, BASAL GANGLIA, 
AND CEREBELLUM. 

Descending from the cortex in converging lines we have the corona 
radiata, the fibers of which bring the brain-mantle into relation with the 
lower brain parts and the spinal cord. Through the corpus callosum the 
homologous cortical elements on the two sides of the brain are brought 
into harmonious relation. The descending tracts reaching the basal 
ganglia are condensed into the internal capsule, in which the cortical 
motor fields are represented from head to foot, in an order from before 
backward, as indicated in figure 76. 

The internal capsule lies between the lenticular part of the striate 
body externally and the caudate nucleus and the optic thalamus on its 
median aspect, but is not dependent upon them. Its anterior portion, 
or limb, is supposed to contain psychic paths to the frontal lobes. 
Lesions of this part of the internal capsule produce no distinctive 
symptoms. The motor routes lower down are continued in the under 
portion of the crura and so on through the pons into the medulla and 
cord. The motor paths and their relations are indicated in figure 77, 
which shows that the face mechanism is inferiorly situated in the cortex, 
anteriorly in the capsule, and internally in the eras. 

The sensory paths, situated in the posterior columns of the cord, pass 
upward into the posterior third of the hinder limb of the internal cap- 



CEREBRAL WHITE MATTER, BASAL GANGLIA, CEREBELLUM. 187 

sule. They reach the cortex of both hemispheres, according to Brissaud 




EYES OPENED 
EYES TURNED 
MOUTH OPENED 

HEAD TURNED 

TOMGUE 

MOUTH RETRACTED 

SHOULDER 

ELBOW 

WRIST 

FINGERS 

THUMB 

TRUNK 

HIP 

ANKLE 

KNEE 

HAU.U* 

rocs 



Fig. 76. — Arrangement of motor paths in the internal capsule (after Ferrier). 



and others, directly on the same side and indirectly on the opposite side, 
by sending off a branching path through the corpus callosum, as shown 




Fig. 77.— Diagram to show the relative position of the several motor tracts in their course from the 
cortex to the cms. The section through the convolutions is vertical ; that through the internal capsule, 
1, C, horizontal ; that through the cms is again vertical ; CN, caudate nucleus ; O, TH, optic thalamus; 
L 2 and L 3 , the middle and outer parts of the lenticular nucleus ; /, a, I, face, arm, and leg fibers. The 
words in italics indicate the corresponding cortical centers (after Gowers). 

in figure 78. Bilateral sensory representation is thus provided for. 
Doubtless motion is originally equally symmetrical in its cortical repre- 



188 



DISEASES OF THE BRAIN PROPER. 



sentation, the apparent functional difference arising from the specializing 
of unilateral motility in the opposite or most intimately related cortex, 
by practice, habit, and education. 

From these diagrams we can understand that lesions in the cerebral 




„NC 



_NR 



Fig. 78.— Schematic vertical transverse section of the hemispheres passing through the internal 
capsule and representing the sensory pathways. G, Left hemisphere ; D, right hemisphere ; cc, corpus 
callosum; ci, internal capsule; SG, sensory pathway from left side of cord; SD, sensory pathway from 
right side of cord. Both sides are brought into intimate relation through the corpus callosum, and the 
sensory representation is uniformly bilateral (after Brissaud). 



white matter must be close to the cortex or in the internal capsule to 
produce permanent and definite sensory symptoms, as otherwise placed 
they do not intercept the pathways to both hemispheres. The symp- 
toms in subcortical lesions correspond to the function of the related 
cortex, and in capsular lesions to the function of the particular tracts 
involved. The radiations to and from the cortex in the area of latent 
lesions may be, and often are, involved without giving rise to any 
symptoms. 

The corpus callosum may be diseased to almost any extent without 
presenting any peculiar symptoms. Bristowe, Sharkey, and Schuffer 1 
contend that tumors of the corpus callosum are likely to produce 
hebetude, apathy, and prolonged placid coma. If its function is but 
to furnish correlating tracts between the two sides of the brain, its 
destruction would not materially interfere, perhaps, with the independent 
action of the half-brain. Putnam and Williams 2 note that in tumors 
of the corpus callosum mental changes are the only common symptoms, 
these consist in changes of character, impairment of memory and men- 
tality, stupor, hallucinations, irritability and attacks of excitement. 
Epileptoid attacks, hemiplegia passing into diplegia most pronounced in 
the legs, and a peculiar ataxia or apraxia, a sort of lack of balance, and 
a poverty of movement have been variously recorded. 

1 "Rev. Speriment.," vol. xxviii, p. 2. 2 "Jour. Nerv. and Ment. Dis.," Dec, 1901. 



CEREBRAL WHITE MATTER, BASAL GANGLIA, CEREBELLUM. 189 

Lesions involving the optic radiations in the occipital lobes produce 
hemianopsia, and when on the left side they cut the radiations from the 
occipital apex to the angular gyre, word-blindness ensues, as described 
on page 182. Lesions beneath the auditory word-centers likewise pro- 
duce word-deafness. 

The function of the corpora striata is still a matter of speculation. 
Lesions affecting them, however, almost invariably implicate the 
capsular tracts. In this locality we encounter the hemorrhagic lesion 
that is preeminently causative of apoplectic hemiplegia. Whether or 
not posthemiplegic choreic movements and athetosis are due to disease 
of the basal ganglia cannot be definitely stated, but lesions in this 
locality are frequently attended by such motor disorders. S. A. K. 
Wilson 1 groups a number of cases under the title of progressive lentic- 
ular degeneration, a familial disease associated with cirrhosis of the 
liver. He defines this disease as one which occurs in the young, is often 
familial, but not congenital or hereditary; is essentially a disease of 
the extrapyramidal motor system characterized by involuntary move- 
ments, such as tremor, dysarthria, dysphagia, muscular weakness, 
spasticity, contractures, and emaciation. There may be emotionalism 
and mental symptoms. It is progressive and fatal. It presents bilateral 
degeneration of the lenticular nucleus and cirrhosis of the liver, of which 
latter feature no clinical symptoms obtain. 

The optic thalami, when diseased, give rise to no definite symptoms 
if the lesions are confined to their anterior portions and do not invade 
the capsule. When the hinder portion of the optic thalamus is involved 
we are likely to have either a crossed blindness or a double hemianopsia, 
probably from simultaneous injury to the optic tract. Bechterew claimed 
that facial emotional expressions are controlled by the thalamus in some 
manner. Brissaud, in cases of postparalytic spasmodic crying and laugh- 
ing, locates the lesion near the knee of the internal capsule. The loss of 
facial emotional expression at least points to the internal capsule and the 
optic thalamus rather than to the cortex. Roussy, with whose conclu- 
sions Dana 2 is in substantial accord, outlines a somewhat definite thala- 
mic syndrome. It is characterized — (1) by slight hemianesthesia and 
hemiparesis, without contractures and persistent exaggeration of the 
reflexes; (2) by hemiataxia, hemiastereognosis, persistent pains, and 
paresthesias on the affected side, and (3) a tendency to choreoid and 
athetoid movements. To these Head and Holmes 3 add a tendency to 
react excessively to unpleasant stimuli on the affected side. The prick 
of a pin, painful pressure, excessive heat or cold, produce more distress 
than on the normal side of the body. 

The corpora quadrigemina are seldom singled out by brain-lesions. 
When involved, adjoining structures almost invariably suffer, so that 
the resulting symptoms are difficult to analyze. The anterior pair are 
associated with vision, and apparently with some ocular movements. 
The pupillary reflex and movements of the eyeballs have been bilaterally 
impaired in some cases when they were diseased, and nystagmus, en- 
feebled vision, and blindness have been noted. 4 The posterior pair are 

1 "Brain," March, 1912. 2 "Jour. Am. Med. Assoc," Dec. 18, 1909. 

3 "Brain," 1911. 4 Biancone, "Rev. Speriment.," Dec, 1899. 



190 DISEASES OF THE BRAIN PROPER. 

thought to be related to hearing and equilibration. When they are 
diseased, the adjoining portion of the middle cerebellar lobe is usually 
involved, and probably gives rise to the symptoms mentioned. Ray- 
mond 1 contends that circumscribed lesions limited to the region of the 
corpora quadrigemina are prone to present (a) diminution of visual 
acuity, (b) palsies of associated ocular movements, (c) pupillary anoma- 
lies, (d ) paresthesias on one or both sides of the body, (e) ataxic dis- 
orders of movement in the limbs, (/) athetoid and choreiform move- 
ments, (g) contralateral diminution of hearing, (h) rarely disturbance 
of mastication by implication of the motor root of the fifth cranial nerve. 

The crura cerebri contain the motor tracts on their under portions 
and the sensory tracts above. Crural lesions, therefore, produce hemi- 
plegia of the face and limbs on the opposite side, marked by hemi- 
anesthesia if the sensory paths are at the same time involved. The 
proximity of the third nerve, as it issues from the inner border of the 
crus, lays it liable to damage at the same time, and then we also have 
an ophthalmoplegia. This affects the eye on the same side as the lesion 
and opposite to the paralyzed limbs. — the Benedict- Weber syndrome. 
When the lesion is deep, it gives rise to nuclear disturbance, as de- 
scribed under Diseases of the Cranial Nerves. 

The pons Varolii, when diseased, often presents characteristic symp- 
tom groups that make the localizing diagnosis comparatively easy. It 
will be recalled that besides giving passage to the pyramidal tracts, 
which course downward from the crura to the medulla oblongata, it is 
traversed by the root-fibers of the fifth, sixth, and seventh pairs of 
cranial nerves from their nuclear to their apparent origins. The course 
of the facial fibers and their decussation in the substance of the pons 
opposite the apparent origin of the fifth pair as described on p. 123, 
and shown in figure 44. s_If_a lesion falls upon the facial fibers before 
they decussate, and at the same time involve the pyramidal tract, which 
decussates lower down in the medulla, a paralysis of motion for the face 
and limbs on the side opposite the lesion ensues. If the lesion occurs 
below the facial crossing, — namely, in the lower third of the pons, — it 
will affect the face on the same side and the limbs on the opposite side, 
producing a crossed or alternating paralysis. Whether or not sensory 
symptoms are added depends upon the implication of the tegmental fibers, 
which lie above or behind the motor tracts. When this is the case the 
motor nucleus of the sixth nerve or its root-fibers is usually implicated 
at the same time, so that conjugate deviation of the eyes toward the 
side of the lesion and away from the paralyzed limbs is impossible. In 
destructive cerebral lesions higher up, it will be recalled, the ocular 
deviation is toward the lesion and away from the paralyzed limbs. 
Pontine disease may involve the motor speech-paths, which lie dorsad 
in the median portions of the pyramidal tracts, and give rise to articu- 
lative disturbance very like motor aphasia. Extension of the lesion 
dorsad and cephalad may involve the oculomotor centers. 

The motor and sensory portions of the fifth cranial nerve-root may 
be involved separately or together, and trismus may be induced by irrita- 
tion of the motor nuclei. A lesion which cuts the sensory root-fibers of 

1 "Lecons," Paris, 1901. 



CEREBRAL WHITE MATTER, BASAL GANGLIA, CEREBELLUM. 191 

the fifth induces anesthesia in the face on the same side and crossed 
paralysis in the limbs through injury to the pyramidal tract. Rigidity, 
spasm, and choreoid movements in the limbs are sometimes encountered, 
and convulsions, in acute disease, are common. If the middle cerebellar 
peduncle is affected, vertigo, vomiting, and tinnitus are usually present, 
and deafness on the same side may ensue. Irritative lesions of this 
peduncle produce forced gyratory movements or forced one-sided posi- 
tions in lying, which may be accompanied by corresponding positions of 
the head and eyes in the direction to which the turn is made. This 
mav or may not correspond to the side of the lesion. 

The medulla oblongata, owing to its small size and the vital impor- 
tance of its nuclei, is most rarely invaded by acute disease without an 
immediately fatal termination. Disease of the olivary body may cut 
off the hypoglossal nerve and at the same time cause a crossed paralysis — 
the tongue on the same side and the limbs on the opposite. Diseases of 
this portion of the brain-stem are practically those of the lower cranial 
nerves and embrace the bulbar palsies already considered in Part II. 

The Cerebellum. — According to Luciani, the cerebellum has for its 
main function the maintenance of sthenic tone in the muscular appara- 
tus. If this be impaired, paresis, ataxia, incoordination, asthenia, 
tremors, and astasia result. It seemed probable that the cerebellum 
was practically of a uniform functional quality, which was quite evenly 
represented throughout its entire bulk, and that one part might take 
the place of another. Risien Russell 1 and others have shown that the 
right lobe bears a certain relation to the right side of the body and 
the left lobe to the left side. Rothman contends that from before 
backward in the cerebellar cortex definite sections of the body are 
represented in the following order: eyes, head, face, jaws, tongue, 
neck, upper extremities and lower extremities, the trunk being repre- 
sented in the posterior median regions. It is an experimental and clinical 
fact that cerebellar lesions of a sudden and extensive character at once 
produce very marked ataxic and paretic conditions, which may in time 
entirely pass away. Lesions similar or even greater in extent, but of 
slow development, may be entirely devoid of symptoms. It is evident 
that the cerebellum is capable of rearranging its functional relationships 
if gradually disturbed, and is of great recuperative powers after severe 
injury. Much confusion has arisen from confounding the symptoms of 
the secondary involvement of adjoining structures with those purely 
cerebellar. 

We can now say that the right cerebellar hemisphere is in relation with 
the right side of the body and likewise with the left cerebrum. Man- 
gazzini 2 has shown that injury to the thalamus induces atrophy of the 
opposite cerebellar half, and we thus have a crossed lesion, involving the 
cerebellum on one side and the cerebrum on the other. With the thal- 
amic lesion the corona radiata and motor cortex are usually involved. 

A lesion in one lateral cerebellar hemisphere, if occurring with suffi- 
cient rapidity, as from hemorrhage or quickly developing abscess or tumor, 
produces sthenic loss on the same side of the body. This becomes mani- 
fest in one-sided muscular weakness or readiness of fatigue, in decreased 

1 "Brit. Med. Jour.," May 18, 1895. 2 "Neurol. Centralbl.," Aug. 1, 1895. 



192 DISEASES OF THE BRAIN PROPER. 

coordination, in a tendency to stagger, and as the side of the lesion is the 
weaker side, the stagger is more marked in this direction, — that is, a 
patient with right-sided cerebellar disease is inclined to follow his right 
hand. Babinski, 1 under the name of adiadococinesia, has particu- 
larized the difficulty presented by such patients in repeating a move- 
ment with rapidity and uniformity. This is commonly tested by ask- 
ing for movements of pronation and supination of the forearm 
which quickly lose in uniformity and promptly subside from fatigue. 
A patient with cerebellar tumor found it impossible to use the salt and 
pepper shakers. The reflexes are also unilaterally reduced. At the same 
time the trunk may deviate to the sound side from the preponderating mus- 
cular tone on that side. Weakness of the ocular muscles on the same side 
as the lesion produces a tendency of the eyes to deviate in the opposite 
direction, and strong attempts to turn them toward the side of the lesion 
often develop nystagmic or jerky movements. It seems probable that 
lesions toward the head of the worm produce a tendency to fall forward, 
those toward the tail of the worm, a backward falling. These are the 
paretic manifestations. The cerebellar stagger and the ocular disturb- 
ance are often attended by vertigo of a pronounced subjective sort. Very 
commonly this is greatly intensified if the patient attempts to stand or 
even to sit up, and may prevent his doing so. In other cases, when the 
so-called cerebellar gait is well marked, there is no attending vertigo. 
Vertigo of a similar character may attend a tumor in the frontal region, 
which at the same time may cause an occipital headache and, according 
to Williamson, 2 in one-fifth of such cases induces bilateral weakness of 
the reflexes. 

Irritative lesions produce another group of symptoms. They are 
marked by muscular stiffness in the extremities of the same side, by nys- 
tagmus, in which the jerk is toward the side of the lesion, and by such an 
arching of the body with the concavity to the diseased side as tonic excess 
on the affected side would produce. Emprosthotonos and opisthotonos 
would perhaps point to the middle lobe or to both lobes. Drummond 3 
has also noted convulsions of a tetanoid character on the same side as the 
lesion, and Ferrier has recorded them in animals subjected to operation. 
The activity of the lesion dominates the symptoms. They grade off in 
proportion as the diseased process is slow and may easily reach a vanish- 
ing-point in chronic conditions that sometimes are astonishingly extensive. 

A third group of symptoms arises from extension of the cerebellar 
disease to neighboring structures, or from pressure upon them. A one- 
sided cerebellar tumor, for instance, by extension forward above the 
medullary decussation, presses upon the motor tract from the cerebrum 
to the cord and gives rise to spastic symptoms on the side opposite the 
lesion, with increased myotatic irritability and even a tendency to con- 
tractures. Pressure upon the floor of the fourth ventricle may affect the 
nuclei of the cranial nerves and give rise to paralysis of the fifth, sixth, 
seventh, eighth, ninth, tenth, and twelfth pairs of cranial nerves. The 
eighth or auditory nerve is particularly liable to be affected, and then 
aural symptoms are added. Tinnitus and vertigo of the Meniere variety 

1 "Rev. Neurologique," Nov. 15, 1902. 2 "Glasgow Med. Jour.," Nov., 1899. 

3 "Lancet," July 28, 1894. 



CEREBRAL WHITE MATTER, BASAL GANGLIA, CEREBELLUM. 193 

may be superinduced, adding greatly to the complexity of the clinical 
picture. It is needful to investigate the aural condition very critically, 
as aural vertigo and cerebellar disease are often associated by the ex- 
tension to the cerebellum of septic processes in the ear, and labyrinthine 
disease may closely imitate a cerebellar lesion. (See page 136.) Irrita- 
tion in the fourth ventricle may produce polyuria and glycosuria. 
Obstruction of all Galenic veins produces dropsy of the ventricles, 
their distention, and all the manifestation of intracranial pressure. 
Sudden death may follow disturbance of the pneumogastric nuclei. 
If the middle peduncle — the peduncle to the pons — be affected, forced 
movements result and forced positions are developed. These seem to be 
toward the opposite side if the lesion is irritative and toward the same 
side if destructive. Other clinical manifestations are those common to 
all intracranial diseases, — namely, headache, vomiting, optic neuritis, 
and vertigo. Of these an occipital headache is significant and is often 
associated with a rigidity of the neck and retraction of the head. Friede- 
berg 1 found this retraction marked in over half of the cases of cerebellar 
tumor in Aufrecht's clinic. Sensory disturbances are rare. Russell 
is inclined to think they may be present for a short time immediately 
after the onset of acute diseases, as hemorrhage and transient anesthesia 
are noticed in operated animals. Krauss, 2 from a study of ninety-seven 
cases of cerebellar disease, enumerates the frequency of symptoms in 
this order: "Headache, vomiting, optic neuritis, vertigo, ataxia, asthenia, 
occipital pain and tenderness, inclination to turn toward the side of 
lesion, convulsions, and such secondary symptoms as nuclear paralysis, 
polyuria and glycosuria, tremors, and sudden death." Neither the 
mind nor the sexual desire is necessarily disturbed. 

A combination of pontine, cranial nerve, and cerebellar symptoms 
is presented by tumors occurring in the cerebellopontine angle formed 
by the lateral lobe of the cerebellum and the medulla and pons. The 
fifth, sixth, seventh, and eighth nerves traverse this area and show 
various combinations of symptoms, depending upon their partial or 
complete implication. Encroachment of the growth upon the cere- 
bellum adds symptoms of a corresponding nature and crossed palsies 
due to pontine disturbance are also encountered. Combinations of 
eye symptoms, such as squints and nystagmus, of ear symptoms, such 
as tinnitus and vertigo, of disturbance of sensation in the domain of 
the fifth nerve with diffuse symptoms of brain tumor and cerebellar 
indications, would furnish a syndrome almost characteristic of tumor 
in the cerebellopontine angle. The recognition of this syndrome is 
very important, as in tumor cases surgical technique and experience 
now offer a very favorable prospect to properly conducted operations. 
1 "Berlin, klin. Wochens.," Aug. 19, 1905. 2 "N. Y. Med. Jour.," June 1, 1895. 
13 



194 DISEASES OF THE BRAIN PROPER. 

CHAPTER IV. 

FURTHER LOCALIZING CONSIDERATIONS. 

Lesions of the brain may be broadly considered as irritative and 
destructive. From this point of view they respectively produce increased 
and decreased activity of function. We find the best exposition of 
these conditions in lesions of the motor cortex. Given a circumscribed 
definite lesion, such as that caused by spiculum of bone or a small tumor, 
that rather displaces than destroys the cortical elements in this region, 
and it is likely to so irritate them that increased activity is manifested 
in the peripheral area with which they are associated. A limited spasm 
or convulsion may ensue. If the irritation be too long maintained, 
necrotic or destructive cortical changes usually follow and are marked 
by diminished or completely lost peripheral function, — namely, paresis 
or paralysis. A lesion, at first irritative, may thus induce spasms in the 
hand, and after a time the hand becomes paretic if the progress of the 
disease reaches a destructive grade. Sudden destruction of the cortical 
mechanism, as by hemorrhage, causes immediate loss of power. 

Were all lesions simply destructive or irritative, difficulty in decipher- 
ing them would be greatly reduced, but ordinarily they are combined in 
varying degree. Around a destructive process a zone of irritation 
brings new elements of disturbance into the symptom-field which, in 
turn, may be replaced by evidence of extending destruction. Again, 
in an area practically paralytic from cortical disease, convulsions may 
occur, perhaps owing to irritation of remaining but inhibited cellular 
elements or from irritation of the subcortical tracts. In every case, 
therefore, it is highly important to know the clinical sequence of irrita- 
tive and paralytic symptoms in order to determine the point of invasion, 
the progress of extension, and the limits of the lesion. 

This brings us to the invasion or extension symptoms. These are 
transient in the widening convulsive manifestations of cortical epilepsy, 
and permanent in the slow encroachments of progressive disease. If 
we consider an irritant or discharging lesion to be located in a given 
part of the cortex, the disturbance to which it gives rise spreads in con- 
centric and widening circles to the adjoining regions, which are succes- 
sively upset, and the peripheral display is correspondingly and similarly 
broadened. The invading march of a Jacksonian fit can be foretold if 
we know its initial location or storm-center. Concentric rings on corti- 
cal diagrams enable us to grasp this point firmly. In figure 79, A y a 
fit starting in the arm-center would next call forth the face and head 
movements, then those of the trunk, and finally those of the lower ex- 
tremity. Commencing in the lower extremity, the order would be re- 
versed, as shown in figure 79, C. These sequences are in accordance 
with clinical facts. The order of convulsive invasion is not one of 
chance, but is rigidly dominated by the anatomical and functional rela- 



FURTHER LOCALIZING CONSIDERATIONS. 



195 



tions of the cortex. The initial or signal symptom of a cortical fit, 
therefore, becomes highly significant as pointing to the storm-center, the 
point of greatest instability and usually the seat of organic disease. 

Considerations of a similar character sometimes enable us, if we have 
all the clinical data available, to trace a neoplasm from its origin as it in- 
vades neighboring centers, and to relatively estimate its anatomical limits. 
The area of latent lesions must be 
kept in mind. It gives no special 
symptoms when traversed by the 
discharge of a fit or when invaded 
by a growth. The cortical fields of 
speech and of the special senses are 
subject to the same rules as the 
motor zone. Their invasion is at- 
tended by aphasic or sensory dis- 
turbances. In the latter case hallu- 
cinations are likely to appear, and 
may constitute the signal symptom 
of Jacksonian fits. Thus, patients 
may always hear a certain sound, see 
a certain spectrum, smell or taste a 
certain article as the fit comes on. 
In such cases the application 
of concentric cortical lines shows 
that the subsequent motor dis- 
turbance was subject to the same 
invasion rule that obtains when 
the storm arises in the central con- 
volutions. 

Peripheral sensory disturbance 
arising from cortical lesions is usu- 
ally of a paresthetic sort. There may 
be some blunting of cutaneous, mus- 
cular, and joint sensations, but persis- 
tent anesthesia is extremely rare 
except in bilateral lesions. The 
double and complete representation Fig. 79 -schematic figures to show the en- 

1 I m croachnieut of waves of discharge in the cortex, 

Of Sensation has been Sufficieiltlv in- beginning respectively in the arm, face, and 

, * leg centers. F, Face: B, arm; J, leg (alter 

SlSted Upon (see p. 188). In Jack- Brissaud). (Centers F and B should be placed 

p , . , • • , • 1 • on the precentral gyre.) 

soman tits the initial symptom is 

often a peculiar sensation or pain localized in or near the part 
that is first thrown into spasm. Patients are frequently at a loss to 
describe these sensations, and they vary from slight discomfort or slight 
formication to severe pain and intense burning. Their distribution 
is segmental or functional and does not conform to the peripheral 
nerve-supply. They are tolerably uniform in quality and distribution 
in any given case. Exhaustion of the motor apparatus after severe, and 
particularly after repeated, attacks of Jacksonian fits may lead to a paralysis 
lasting several days or weeks and a mistaken idea of brain destruction. 




196 DISEASES OF THE BRAIN PROPER/ 

From another point of view cerebral symptoms are diffused or local- 
ized. The great majority of endocranial lesions are marked by headache, 
vertigo, vomiting, mental disturbance, and often by optic neuritis. As 
these do not necessarily depend upon the part involved, they have little 
localizing value, but the presence of several of them is highly suggestive 
of brain disease. 

Headache is a very usual symptom. It is pronounced in the cases 
which involve the meninges. Its importance in meningitis will be at 
once recalled. In syphilitic cerebral disease it has a marked tendency 
to come on toward night. Cerebral headaches are usually very intense 
and very refractory to sedatives. Lesions which do not impinge upon 
the cortex or meninges may give rise to no headaches whatever, unless 
pressure conditions arise, when the superficial portions of the encephalon 
are disturbed and pain ensues. Cerebellar disease is frequently attended 
by an occipital headache and a tendency to retraction of the head. The 
location of the headache is not always in close relation to the lesion. 
For instance, cerebellar disease has caused intense frontal headaches, and 
small tumors have given rise to a generalized head-pain. A circum- 
scribed, deep-seated, persistent, and intense headache, however, has 
some localizing value. 

Vertigo attends many brain disorders, and marks nearly all cere- 
bral surprises arising either from without, as by concussion, or from 
within, as from embolism or hemorrhage. Implication of the aural 
apparatus gives rise to the peculiar vertigo described under Meniere's 
Disease (see p. 136). A lesion of the middle cerebellar peduncle causes 
forced lateral movements, usually associated with vertiginous sensations, 
and cerebellar disease is marked by a stagger, into the causation of which 
some vertigo may enter. In a general way we may say that persistent 
vertigo is likely to be allied to diseases of the basal parts. These, too, 
may give rise to the ocular and labyrinthine forms from injury to the 
nerves entering the orbit or vestibule. 

Vomiting in encephalic disease is a common symptom. The pecu- 
liarities which mark cerebral vomiting are lack of gastric disorder and 
nausea, a clean tongue, and the readiness and ease with which the 
stomach rejects its contents. There is very little retching, and the food 
or drink is regurgitated, sometimes with considerable force, in a projectile 
manner. Meningeal invasions of an inflammatory or other character 
often present this symptom. It is very common in disease of the cor- 
pora quadrigemina, the pontine and the cerebellar regions, perhaps from 
more or less irritation of the pneumogastric nucleus. 

All varieties of mental disturbance appear in organic brain disease. 
We encounter momentary unconsciousness in petit mal; hebetude, and 
profound coma in meningitis, apoplexy, concussion, and intracranial 
pressure ; maniacal disturbance after epileptic attacks ; changed tempera- 
ment and character after frontal lesions, and more or less dementia in 
nearly all cerebral paralytics. The diffuse cerebritis of general paresis 
presents its own usually highly colored mental picture. The mental 
attributes of aphasics have been already described. Mental symptoms 
have the same general significance as motor signs. Irritation means 
mental excitement, and overmental excitement leads to hebetude, which 



FURTHER LOCALIZING CONSIDERATIONS. 197 

also directly follows pressure conditions, shock, and deranged cerebral 
circulation. 

Optic neuritis in brain disease has been adverted to under Diseases of 
the Optic Nerve (see p. 101). Its presence in suspected intracranial 
tumor almost serves to clinch the diagnosis. The location of a growth 
or the position of an abscess, or their size, seems to have very little to do 
with the intensity of the papillitis, but it is most common in lesions of 
the basal ganglia and cerebellum. When unilateral, the growth is com- 
monly on the same side of the brain. A neuroretinitis is a common 
symptom and sequence of meningitis. 

The localizing symptoms of brain disease have been set forth in the 
three preceding chapters. In addition we often derive much infor- 
mation from the implication of the cranial nerves that takes place in their 
intracranial course. The various symptoms thus produced are discussed 
under Diseases of the Cranial Nerves. Diseases of the base, the pedun- 
cular, pontine, and medullary portions of the encephalon ordinarily have 
cranial-nerve concomitants. This is also true of lesions of the cere- 
bellar peduncles and of other parts in the region of the series of cranial- 
nerve nuclei. 

Topical symptoms of some value are often encountered in intracranial 
disease, and should always be sought. Traumata, if recent, are usually 
marked by bruises, wounds, or fractures that at once center attention on 
the underlying parts and on the opposite side of the brain where the 
force of the blow is expended. In later cases scars, cranial depressions, 
or evidence of bone disease are equally significant. The presence of 
deformities due to new growths and the conditions of the auditory canals, 
nasal passages, and pharyngeal vault are to be carefully noted. When 
the disease affects the meninges there is often topical pain and tenderness 
that can be elicited by making pressure over the scalp or by going over 
the surface with a percussion hammer. Its outline and permanence are 
suggestive of the extent of disease beneath. A neuralgia of the fifth or 
occipital nerve has its own tender points and anatomical outlines to dis- 
tinguish it. By percussion, Macewen, Starr, and others have been able 
to distinguish a different note over the seat of intracranial growths and 
diseases that were located close to the cranial wall. This, doubtless, 
requires a very acute ear, but should be sought in every suspicious case. 
Intracranial aneurysms may in some cases present a bruit that can be 
heard through the stethoscope. We would naturally expect the patient 
to be aware of it, as the conditions favorable for bone-conduction would 
be present. Two of the writer's cases of extensive intracranial aneur- 
ysm, in which a bruit was probably present, gave expression to no such 
subjective complaint, and auscultation was not attempted before opera- 
tion. In a third, persistent throbbing had annoyed the patient for 
months and then disappeared, but the stethoscope revealed a decided 
bruit, of which she was not conscious. 

In some cases of intracranial disease a localized elevation of tempera- 
ture has assisted the diagnosis. Our present commonly available means 
of surface thermometry are deficient in accuracy. If the bulbs of clinical 
thermometers be passed through pieces of rubber protective and then 



198 DISEASES OF THE BRAIN PROPER. 

applied to the scalp by light bandages, tolerably reliable readings may 
be obtained. It must be borne in mind that the left side of the head 
is usually, in the right handed, about one degree warmer than the right 
side, and that mental activity causes the temperature to go up nearly or 
quite another degree. Sometimes in suspected abscess a thermometer in 
each auditory canal may on one side show local heat even in the absence 
of any apparent local inflammation. Palpation may discover a brain 
tumor, as the cranial wall is often eroded by a cerebral growth, and that, 
too, when situated at a considerable depth. The x-ray has been used 
in many cases of brain disease. In a few instances it has aided in the 
diagnosis of tumor, but in cases of exostosis and other alterations of 
bones, in alterations of the sella turcica due to pituitary disease and 
tumors and in the case of foreign bodies, skiagrams are of the greatest 
value. 

Finally, it is to be borne in mind that a brain-lesion located in a 
latent zone may give rise to symptoms at a distance. In some instances 
this results from interference with the blood -supply or the return circu- 
lation. In other cases the mechanism cannot be explained. In many 
cases where every symptom pointed to the cortex, the disease has been 
found deeply seated. The localizing diagnosis always contains uncer- 
tainties and should be expressed with a fair degree of reservation. Opera- 
tions depending on it are, therefore, exploratory in every instance when 
external guiding signs are lacking. 



ARTERIAL BRAIN DISEASES. 



199 



CHAPTER V. 
ARTERIAL BRAIN DISEASES, 

In the preceding chapters of this part the localizing features of brain 
disease have been considered. They furnish the basis of the localizing 
diagnosis. An equally or more important question is that of the patho- 
logical diagnosis. What is the lesion ? Comparatively few pathological 
processes are found in diseases of the brain, but their effects and re- 
sults are numerous and serious. These diseases fall into groups related 
to : (1) The arterial supply ; (2) the venous return ; (3) inflammatory 
disturbances of the brain-substance, and (4) new formations. Surgical 
conditions, such as penetrat- 
ing wounds, are left to works 
properly covering such acci- 
dents. We first turn our atten- 
tion to the arterial supply of the 
brain. 

Anatomical Considera- 
tions. — The arterial supply 
of the encephalon furnishes 
the anatomical basis of some 
brain-lesions, and presents prac- 
tical points of great impor- 
tance. The left carotid, leav- 
ing the arch of the aorta on 
a tangent that conforms to the 
natural blood-current, favors 
the passage of emboli of car- 
diac origin to the left brain. 
It will be recalled that all 
the blood to the brain proper 

reaches the encephalon by the internal carotids and the vertebrals. 
These four inlets are brought into intimate relation through the 
circle of Willis. From side to side compensation in the circle 
is practically complete in case the lateral arteries are occluded. 
From the carotid or anterior portion of the circle to the verte- 
bral, basilar, or posterior portion, full compensation can not be 
provided owing to the smallness of the connecting arteries. From 
the circle of Willis two distinct systems of arteries arise, — the 
basal and the cortical. From the circle itself, and from about 
the first inch of the six great arteries, the anterior, middle, and 
posterior cerebrals, short, direct vessels plunge into the brain to 
nourish the basal parts, ganglia, and capsules. These anastomose but 
slightly with one another, and are of the nature of terminal arteries. 
Their occlusion or destruction irreparably cuts off the circula- 




Fig. 80.— Charcot's diagram of the circulation at the 
base of the brain. 



200 DISEASES OF THE BRAIN PROPER. 

tion from a given portion of brain-tissue. Those distributed to the 
lenticulostriate nucleus, the internal capsule, and a portion of the 
thalamus are derived from the stem of the middle cerebral. One 
in particular, supplying the third layer of the lenticular ganglion, 
the caudate nucleus, and the upper portion of the capsule, is so 
commonly the seat of rupture that it was denominated by Charcot the 
artery of cerebral hemorrhage. 




Fig. 81. — Distribution of the middle cerebral artery (Duret). 

The main cerebral arteries coursing up over the hemispheres in the 
arachnopia have each a definite cortical territory, and these only slightly 
overlap. They give off two sets of branches, — namely, delicate arteri- 
oles, nourishing the cortex, which they enter at right angles, and larger 
straight, long branches, which pierce the cortex and supply the white 
matter of the cerebrum (see Fig. 66, p. 169). These pass inward and 



Fig. 82.— Showing the distribution of the anterior, middle, and posterior cerebral arteries on the 
surface of the brain. The numerals I, II, III, IV indicate the areas supplied by the different branches; 
the dotted lines indicate the main trunks (modified from Merkel and Debierre). 

almost come into anastomotic contact with the upward-reaching termina- 
tions of the capsular and ganglionic branches arising close to the circle. 
Between these arterial territories there remains an ill-nourished zone 
that is prone to senile softening (Fig. 83). 

The cerebellum receives its blood-supply from the vertebrals and 
basilar ; the medulla and pons are largely supplied by the basilar. It 



ARTERIAL BRAIN DISEASES. 



201 



will be recalled, from the description of the pial vessels (p. 73), that 
their cortical and deeper branches carry with them a periarterial 
lymph-sheath continuous with the pial space. 



CEREBRAL ANEMIA AND HYPEREMIA, 

Cerebral Anemia. — Until recently an undue importance attached 
to the frequently alleged conditions of general brain anemia and 
hyperemia. They were spoken of as morbid entities, and diag- 
nosis stopped at that. We must look upon them as purely symp- 
tomatic and secondary. In many respects they are marked by 
similar or even identical phenomena, and can only be distinguished by 
their associated states or incidental symptoms. The circulation of the 
brain, it will be recalled, is under the direct control of vasomotor centers 
in the medulla and cervical cord. 



r 






T 




It is exceedingly difficult, if not 
impossible, to say where physio- 
logically increased blood-supply 
becomes a morbid congestion and 
entitled to the term hyperemia. 
Cerebral anemia is equally indefi- 
nite. In giving the causes of these 
opposite conditions, therefore, it 
has been found impossible to 
sharply separate the natural from 
the morbid states. Let us first 
consider the anemic brain. 

Etiology. — Cerebral anemia 
is most common in infancy and 
old age, the periods of least brain 
activity. In old age it is the 
legitimate consequence of senile 
arterial degeneration. In adults 
it follows intense emotions, various 
peripheral, acute, painful disturb- 
ances, and shock of all sorts. Tobacco, ergot, belladonna, bromids, anti- 
mony, lead, chloroform, and many other drugs and poisons produce cere- 
bral anemia. Fatty heart, aortic insufficiency, bradycardia, excessive 
hemorrhage, rapid evacuation of peritoneal and pleural effusions are 
attended by cerebral anemia. It takes a prominent place in all the 
general anemias, and in the pernicious varieties is especially marked and 
often attended by nutritional changes in the gray and white matter of 
the brain and spinal cord. Cachectic and exhausting diseases, such as 
cancer, typhoid, phthisis, etc., produce a similar condition. Ligature or 
obliteration of a carotid, or partial occlusion of both carotids or verte- 
brals by atheroma, serve to mechanically produce anemia of the brain. 

Symptoms. — In acute forms of brain anemia, such as are typified 
by an ordinary fainting spell or a great loss of blood, the symptoms are 



3.— Scheme showing the anastomotic re- 
lations^ the basilar and cortical arterial supplies. 
A, Common location of senile softening; B, com- 
mon location of cerebral hemorrhage (after Bris- 
saud). 



202 DISEASES OF THE BRAIN PROPER. 

" darkness before the eyes," giddiness or vertigo, noises in the ears, 
feebleness, trembling of the limbs, nausea or vomiting, sometimes slight 
delirium, and then more or less loss of consciousness. Partial or 
generalized convulsive movements are common, and epileptiform con- 
vulsions are sometimes seen. Finally the condition remits or passes 
deeper into coma, and may terminate in death. The face is usually 
blanched, the pulse small and fluttering, arterial pressure greatly re- 
duced, the pupils dilated, the skin covered with a cold perspiration. 
Similar conditions are seen in shock, and to a moderate degree in some 
cases of migraine. 

In the chronic form, such as attends general anemia and the caehexise, 
patients complain of heaviness of the head, of headaches limited to a 
portion of the head, or a feeling of constriction about the head. They 
sleep lightly or brokenly and their sleep is disturbed by dreams. There 
is mental and physical inertia. They are irritable, peevish, impression- 
able, and somnolent. The pupils are dilated. Vertigo, sometimes 
ringing in the ears, and muscse volitantes are common, and often induced 
by rising from the recumbent position or by a quick turn of the head. 
In extreme cases there may be visual hallucinations and temporary blind- 
ness from retinal anemia. Slight delirium or maniacal states and even 
epileptiform convulsions are seen in severe instances. Optic papillitis 
or choked disc is occasionally encountered. 

The diagnosis is not difficult except in the toxic cases. It must 
be remembered that the circulation in the face, or even in the retina, is 
not a reliable index of the brain state, but is sometimes a helpful guide. 
Anemia of the brain is relieved by placing the head low and intensi- 
fied by the vertical attitude. 

The treatment is that of the underlying causal state or toxic con- 
dition. 

Cerebral hyperemia, like anemia of the brain, is always a secondary 
state, and, while arising from opposite conditions, has many similar sub- 
jective symptoms. It may be recalled that the passing from sleep to 
the waking state is normally marked by increased cerebral circulation, 
as is also the process of active mentation, which is attended by a slight 
increase in the surface temperature of the head, particularly on the left 
side in right-handed persons. ' The brain volume is augmented and in- 
tracranial cerebrospinal fluid is displaced in cerebral congestion. 

Etiology. — Muscular effort, coughing, vomiting, increased heart 
action, impeded respiration, a dependent position of the head, — all tend 
to increase the amount of blood within the skull and produce congestion 
or hyperemia of the brain. Usually the face shows a similar condition. 
Some families display a tendency to plethora and cerebral congestion. 
Menstrual periods are normally marked by an increased circulation in 
the brain. At the climacteric this occurs in flushes or waves and be- 
comes very annoying. Gouty subjects are particularly liable to vas- 
cular disturbance, which frequently involves the cerebral circulation. 
Contracted kidney and arteriosclerosis are also commonly marked by 
such vascular storms. Insolation produces intense cerebral congestion, 
and exposure to cold has a similar effect by driving the blood from sur- 
face to center. In the same way during a chill the central organs are 



ARTERIAL BRAIN DISEASES. 203 

hyperemia The nitrites, opium, alcohol, and the infections of typhoid, 
pneumonia, tetanus, and many fevers produce cerebral congestion. This 
may alone be the cause of the convulsions which so frequently mark the 
onset of eruptive fevers in children. The suppression of menstrual 
discharges or of chronic hemorrhoidal bleeding and pressure on the aorta 
by a tumor or fecal accumulation raises the cerebral blood-pressure. 
Cardiac conditions may cause cerebral congestion by impeding the 
venous return or increasing the arterial tension. Inflammations about 
the head and neck and in the throat are commonly attended by cerebral 
congestion. Brain-tumors and continued epileptic attacks usually cause 
increased cerebral vascularity. 

Symptoms. — Acute cerebral congestion of a marked degree usually 
causes intense throbbing headache, haziness or blurring of vision, and 
sometimes photophobia. It sometimes leads to vertigo, ringing or 
throbbing in the ears, a tendency to somnolence, and if sleep ensues, 
frightful dreams are likely to disturb it. There are mental depression 
and incapacity for thought. There is increased arterial tension. 

Acute cerebral congestion in a grave form occasionally comes on like 
an apoplectic stroke and furnishes an apoplectic equivalent. The patient 
falls inert, unconscious, with stertorous respiration, relaxation of the 
sphincters, and may die. He usually recovers, however, in a day or two. 
Slight paralytic symptoms last several days longer and eventually com- 
pletely disappear. All gradations of cerebral congestive attacks are 
encountered, and, as above indicated, it is often difficult to distinguish 
at what point they become pathological. 

In gouty cases and in various chronic intoxications there is a tend- 
ency in some to delirium, in others to convulsive manifestations, during 
the attack of cerebral hyperemia, These motor and mental excesses 
may reach epileptoid and maniacal stages. 

Chronic hyperemia of the brain is usually a part of organic disease of 
that organ and does not here call for special mention, as its symptomatic 
value is commonly apparent, When it gives rise to symptom groups it 
is by exacerbation in the form of acute attacks. 

The diagnosis of cerebral congestion is commonly easy. The feel- 
ing of fullness in the head, the injected eyes, the flushed face, full arter- 
ies, quickened pulse, contracted pupils, and the increase of all symptoms 
when the head is lowered are sufficiently striking. It is often very 
difficult, however, to distinguish the epileptoid and apoplectiform attacks 
from those of pure epilepsy and gross brain-lesions respectively. In 
the case of apoplectiform attacks in plethoric individuals before the age 
of fifty, especially if they are alcoholic or gouty, the presumption is in 
favor of cerebral congestion and reservation of opinion is in order. In 
epileptiform attacks the history of the case will almost invariably illumi- 
nate the situation. 

The symptom, hyperemia, having been deciphered, it remains to trace 
it to its proper source, and to this treatment is directed. Repeated cere- 
bral congestive attacks in elderly persons foreshadow cerebral hemor- 
rhage and softening. In paretic dementia they are likely to be followed 
by apoplectiform attacks and a rapid downward course. In other in- 
stances their significance is strictly related to their cause. 



204 DISEASES OF THE BRAIN PROPER. 



CEREBRAL ARTERITIS. 

Immense importance attaches to disease of the cerebral arteries, not 
so much on their own account as because of the dire consequences of 
hemorrhage and softening which they may entail. 

Acute arteritis in the brain may follow infectious diseases, such as 
typhoid, variola, diphtheria, scarlet fever, measles, and puerperal infec- 
tion. All the arterial tunics are involved, but distinct symptoms do not 
arise unless thrombosis ensues. This is particularly liable to occur, as 
the intima is often much thickened. The arterial inflammation in many 
instances arises first in the vasa vasorum, and is thence propagated 
to the arterial trunks. The softening that ensues may, according to 
Turner, be followed by cerebral hemorrhage. 

Peri-arteritis is a descriptive term applied to a proliferating affec- 
tion involving the external arterial coat. It is attended by diffuse or 
circumscribed thickenings and connective-tissue increase. The perivas- 
cular sheaths of the cerebral vessels become choked. This, taken with 
the Aveakened arterial wall, favors the formation of saccular dilatations. 
In many instances the cerebral vessels become beaded with minute aneur- 
ysms, which are prone to develop at the branching points. In them- 
selves these miliary aneurysms favor rupture, and the fatty degeneration 
of the arterial and capillary walls increases this danger. As a fact, they 
are the almost invariable source of cerebral hemorrhage, and can usually 
be found by carefully washing out the clot. 

Peri-arteritis is frequently caused by, or at least associated with, 
Bright ? s disease. It may be induced by tubercular infection, which 
usually invades the cranium by the arterial route. It is a concomitant 
of the involution of advanced years and of arteriosclerosis. Syphilis 
may produce it, as may gout, rheumatism, and alcohol. Symptoms are 
very vague and indefinite, or absent, until hemorrhage or infarction gives 
rise to plegic disturbances. The condition should be suspected in chronic 
Bright' s disease and in cases showing arterial degeneration elsewhere. 

Chronic arteritis, atheroma, endarteritis deformans, is frequently 
found in the large cerebral vessels, particularly those at the base, 
and especially the basilar. The atheromatous plaque originates in 
the occlusion or inflammation of the nutrient artery, or vasa vasorum. 
This produces an infarct largely confined to the middle tunic of the ves- 
sel, and the fatty degeneration that ensues is eventually replaced by 
calcareous deposits. The vessel may be completely encircled by such 
a patch, or numerous atheromatous islands may be found. By their 
coalescence the entire artery becomes rigid and brittle. At first the 
intima covers the plaques smoothly, but it is prone to break down, leav- 
ing the calcareous matter exposed in the blood-stream. This frequently 
leads to local deposits of fibrin from the blood, which may cause throm- 
botic closure of the vessel or wash away in embolic masses or particles, 
to produce disturbance farther along the course of the arterial current. 
In the same way calcareous particles may be cast into the stream, and, 
lodging in the narrowing channel, cause secondary mischief. An- 
other effect of atheroma is to narrow the lumen of the affected vessel 



ARTERIAL BRAIN DISEASES, 205 

through the thickening of its walls and the swelling of the internal coat. 
Again, by weakening the vessel- wall, atheroma may produce dilata- 
tion and lead to an aneurysm. The small arteries arising at the seat of 
atheromatous invasion may be occluded, though the parent vessel re- 
mains pervious. Collateral territories are thus cut off, while the ulti- 
mate distribution remains active. The rigidity and brittleness of the 
artery favor rupture and hemorrhage. 

Atheroma may be considered as a purely senile condition in many 
cases, a part of the involutionary changes of the organism in advanced 
years. There is no doubt that gout, rheumatism, great muscular strain- 
ing, overindulgence in alcohol, lead poisoning, and syphilis are addi- 
tional causes. Lancereaux says chronic malarial infection may cause 
atheroma. Causes are frequently combined in a given case, as gout 
and senility. Atheroma, though usually found after middle life, 
has been noted in the aorta and large systemic vessels in children and 
even in infants. 

The symptoms of atheroma of the cerebral vessels are usually vague 
and uncertain until thrombosis, aneurysm, or hemorrhage has been added. 
It may be reasonably suspected when the condition in the heart, aorta, 
and palpable systemic arteries indicates its generalized distribution. 
Protracted nosebleed after middle life is generally due to arterial de- 
generation of carotid branches in the nasal spaces and a rather common 
forerunner of cerebral arterial accident. 1 Lesion of the optic chiasm 
by bilateral atheromatous thickenings of the carotids pressing upon it 
has been noted. Double temporal hemianopsia may thus be produced. 
The formation of an aneurysmal tumor gives rise to its own localizing 
symptoms. Resulting hemorrhage and thrombosis present symptoms 
related to the structures that are injured or destroyed. 

The treatment of atheroma is practically the same as that of arterio- 
sclerosis. 

Arteriosclerosis, arteriocapillary fibrosis, is always a general- 
ized systemic condition, but it may be more accentuated in certain 
bodily organs and there give rise to local symptom groups. Its effect 
upon cerebral activity is most important. According to Sansom, the 
changes brought about are due to a poison circulating in the blood, which 
acts upon the fibroid elements of various tissues, but preeminently upon 
those of the arterial channels. The essential histological modification 
consists of a fibroid proliferation or fibrosis. In certain locations this 
acts mechanically to strangulate associated structures, as, for instance, in 
the arteries, where the muscular fibers are thus invaded and even dis- 
placed. The walls of the . entire arterial system become thickened. 
This may be due : (1) To thickening of the internal coat, which may go 
on to the complete obliteration of small vessels, or (2), commencing first 
in the external wall, the disease may spread inward, usually causing at 
first some hypertrophy of the muscular coat, or (3) the fibrosis may 
originate outside of the arterioles, which are involved secondarily by 
extension of the process to them. The various initial locations of the 
disease seem to depend upon the mode of the poisonous invasion. In 
one instance it affects the intima directly from the blood-stream, in 
1 K. Kompe, "Arch. f. Laryngol.," 1899. 



206 



DISEASES OF THE BRAIN PROPER. 



another the outer coat from the perivascular or lymphatic space, and in 
the third variety the fibrous structures of parenchymatous organs are 
disturbed through the lymph-channels. All these varieties may be 
found in the same case. 

This condition has a number of pathological associations. Atheroma 
is present in about one-half the cases. Cardiac hypertrophy and dilata- 
tion, hepatic cirrhosis, Bright' s disease, asthma, angina pectoris, and 
mitral stenosis are frequently associated and due to identical changes. 
The effect of arteriosclerosis is to diminish the arterial caliber and 
thereby lessen nutrition. This may reach a complete degree and in the 
brain give rise to localized anemia and softening. 

The nature of the poison which stimulates the fibroid activity is 
obscure. Loomis says the " general fibrosis has its origin in a fibroid 
diathesis either hereditary or acquired/' but this explains nothing. By 
some writers defective elimination, particularly that from the kidney, is 
accused. Arteriosclerosis is certainly an accompaniment of old age and 
is a fair index of the wear and tear the individual has undergone and of 



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Fig. 84.— Arteritis : thickening of all the coats (Delafield). 



the remaining vital capacity. We find it often a marked family charac- 
teristic. It is also clear that chronic intoxications by alcohol, lead, gout, 
rheumatism, and syphilis favor it strongly. Overeating, repeated mus- 
cular strains, and intestinal, renal, muscular, and cutaneous sluggishness 
count for something in its causation. 

The cerebral symptoms produced by arteriosclerosis cover a wide 
range, but are all due to faults of brain-nutrition. They embrace those 
of senility, premature senility, and degenerative processes, both chronic 
and acute. The highest and most delicate brain-functions are likely to 
be first affected. We, therefore, find lessened mentality, aphasia, and 
monoplegias or mere clumsiness of the hands. Paresthesias are very 
common. Hemiplegic and diplegic manifestations are observed. At first 
these symptoms are temporary and recurrent, but unless the arterial 
condition improves, they tend to become more and more continuous 



ARTERIAL BRAIX DISEASES. 207 

and permanent. Slight attacks of hebetude or sleepiness may eventuate 
in stupor, coma, and even in death. Jacksonian and generalized con- 
vulsions, syncopic attacks, and periods of mental confusion are all within 
the range of this protean malady. If the fibroid change occludes a 
cerebral vessel, it acts like a thrombus, to which, indeed, it often leads, 
and a softened infarct results in permanent loss of localized brain- 
function. Many islands of softening and many sclerotic patches may 
be due to this cause and present multiple symptoms. Diffuse sclerotic 
processes in the cortex are associated with it, and it underlies some 
of the cerebral lesions of general paresis and tabes. Associated minor 
symptoms, such as vertigo, headache, insomnia, irritability, lack of mental 
energy and muscular force, and the craving for stimulants, all point to 
the lowered nutrition of the brain. All the manifestations of cerebral 
arteriosclerosis are likely to come at first in gusts and waves. 

Symptoms. — The physical examination of a case of arteriosclerosis 
usually demonstrates a tortuous, rigid, frontal artery, sometimes moving 
under the skin in a vermicular manner at each pulse-wave. The cornea 
commonly is the seat of a marked senile arcus. The radials, brachials, 
femorals, and all palpable arterial trunks are tense and rigid. The pulse 
is one of high tension. A light finger imperfectly detects it, but it seems 
to increase as pressure is applied and can hardly be obliterated. The 
sphygmomanometer gives abnormally high readings. There is usually 
an enlarged, laboring heart, and often roughened valvular sounds. The 
second sound is invariably accentuated. The urine is likely to show al- 
bumin and the formed elements that mark chronic nephritis. Often the 
quantity of urea is scanty or markedly deficient. Cirrhosis of the liver 
is common. A constipated habit is the rule, and the general health is 
below par. In less advanced cases the general indications of the arterial 
state may be very slight and yet the cerebral mischief may be extensive. 
This is especially true in the syphilitic varieties. The same processes 
that take place in cerebral structures affect the cord, and may, and often 
do, give rise to organic mischief, furnishing the basis of many system- 
atized and unsystematized cord-lesions. 

The treatment of arteriosclerosis affecting the brain must be under- 
taken at an early stage if much is to be accomplished. Toxic causes, if 
present, must be eliminated. Syphilis, gout, lead poisoning, alcohol- 
ism, renal, pulmonary, and cardiac conditions must receive their 
appropriate management. The arterial spasm due to the local irri- 
tation of the muscular tunic, and perhaps also to uric products in 
the circulation, must be overcome. To relieve the spasm the nitrites, 
especially nitroglycerin, may be given at short intervals. Mercurials 
and much drinking water to cleanse the intestines and stimulate the 
kidneys are valuable aids. Alkaline waters such as Vichy and the lithia 
waters are good. Unless the water is freely excreted it will cause an 
increase of arterial pressure which is to be avoided. Care of the digest- 
ive tract and of the diet is of the first importance. All excesses must 
cease. A simple, easily digested regimen, with a very limited amount 
of red meats, starches, and sugars, should be ordered. The skin should 
be kept active by baths, frictions, and massage. If muscular exercises 
are for any reason contraindicated or not available, massage may take 



208 DISEASES OF THE BRAIN PROPER. 

their place. An outdoor habit should be cultivated, and change of 
scene may do much to reduce the mental distress and vague broodings. 
Of all medicine directed toward improving the arterial condition, the 
iodids easily hold first rank, but it should be remembered that the 
potassium salts depress the heart's action and perhaps add to the arterial 
overtension. Sodium iodid is much to be preferred and is usually 
better tolerated. This should be given in doses of from five to twenty 
grains after meals, and continued for months and years, with short 
intervals. A good plan is to order the iodid discontinued during every 
fifth week. Tonics are almost invariably required. Arsenic can be 
readily given with the iodid, and strychnin is perhaps the best aid to the 
laboring heart. Avoid digitalis and everything else that tends to in- 
crease arterial tension. No harm seems to come from the frequent use 
of amyl nitrite or trinitrin, and the prompt, though transient, relief pro- 
duced is often very gratifying, besides in a way confirming the diagnosis. 

Under such a plan of treatment, aphasias, mental disturbance, 
hemiparesis, and many other symptoms of brain disturbance will some- 
times rapidly clear up and, if not cured, remain in abeyance for years, 
provided moderation in all things be the rule of life. The prognosis, 
however, should be guarded, as we know that brain-cells degenerate 
beyond recovery if entirely deprived of their blood-supply for a few 
hours. At best it is evident that the presence of arteriosclerosis signifies 
a shortened life-lease. 

Syphilitic Arteritis. — It is now generally recognized that cere- 
bral arteritis from syphilitic infection may be a comparatively early 
manifestation of the disease. Ogilvie shows from Naunyn's statistics 
that syphilitic diseases of the cerebrospinal axis present the greatest pro- 
portion of cases during the first year following the initial lesion, but they 
may appear even after a score of years. The basilar, carotids, circle 
of Willis, and large cerebral arteries are those usually implicated, but 
smaller brain-arteries may be similarly diseased. The specific inflam- 
mation may produce a peri-arteritis and nodular plaques that look some- 
thing like those of atheroma, or it may invade and infiltrate all the 
arterial walls with gummy products, commencing either as an endarter- 
itis or a peri-arteritis. Long-standing syphilitic arteritis, especially of the 
large vessels of the base, produces a sclerous degeneration that does not 
calcify. It is generally circumscribed in small patches, causing bulging 
of the internal and external coats, deforming the artery and altering its 
capacity. 

Syphilitic arteritis leads to : (1) Obstruction of the vessel by the pro- 
duction of thrombosis or by an obliterating endarteritis ; (2) rupture 
and hemorrhage, and (3) aneurysm. It may appear at any age and 
may follow inherited syphilis in children and even in adults. 

The most prominent indications of syphilitic disease of the cerebral 
arteries are the prodromata. Of these the syphilitic headache, coming on 
usually toward evening and lasting until midnight, is the most distinct- 
ive. Except that due to tumor, it is the most intense and unmanage- 
able headache with which the physician is called upon to deal. Or- 
dinarily it is not confined to any portion of the head, but is described as 
being somewhat superficial, unlike the deep-seated pain of tumor. Un- 



CEREBRAL HEMORRAGE AND THE HEMIPLEGIC STATE. 209 

less the condition is now recognized or, as is rarely the case, sponta- 
neously subsides, disturbances in the cortex are likely to appear, marked 
by paresthesias and loss of power in the extremities or disturbance of 
speech and the special senses. After vacillating symptoms of this 
character, which have a tendency to recur at intervals of a few days 
or weeks, an apoplectic stroke, due to sudden rupture of the vessel, 
may ensue, or a complete thrombosis lead to cerebral softening. AVhen 
hemorrhage or thrombosis takes place the headache usually disappears, 
or sometimes it disappears a few days before the onset of serious results. 
The symptoms are those of cortical irritation and the eventual onset of 
paralysis is usually not marked by complete loss of consciousness, ex- 
cept in the hemorrhagic form, and coma is the great exception. Apha- 
sia, facial paralysis, monoplegia, paresthetic tinglings, preceded by a his- 
tory of violent headache, with nocturnal exacerbations, strongly indicate 
syphilitic disease of the cerebral arteries, even in the absence of any his- 
tory of specific infection. As has been shown by Charcot, almost invari- 
ably there is some degree of basilar syphilitic meningitis in these cases and 
transient or permanent disturbance of the ocular apparatus is often added, 
added. 

According to Charrier and Klippel, the chief groups of cerebral mani- 
festations of syphilitic disease of the arteries are : (1) Apoplexy ; 
(2) paralysis from obliterating arterial disease ; (3) slight aphasia and 
transitory varying palsies, and (4) intellectual disturbance somewhat sim- 
ilar to that of general paresis. Syphilis is the basis of true general paresis. 

The treatment of the condition should be energetic even when it is 
diagnosed early, and will be discussed at length under the consideration 
of General Syphilitic Diseases of the Xervous System. 

Acute arterial degenerations of an amyloid and fatty character 
affecting the cerebral vessels may follow numerous states marked bv 
various svstemic infections. Onlv in very rare instances do thev give 
rise to marked cerebral symptoms, and these are usually overshadowed 
by the general state. Rupture and hemorrhage or thrombosis and 
softening may be due to them. 



CHAPTER VI. 



CEREBRAL HEMORRHAGE AND THE HEMIPLEGIC 

STATE, 

Excepting traumatic cases, hemorrhage into the substance of the 
brain is a secondary or terminal effect of degenerative or inflamma- 
tory disease of the cerebral blood-vessels, almost invariably of the 
arteries. Usually of comparatively slight seriousness in itself, the re- 
sulting injury or destruction of important brain-structures entails per- 
manent disability if an early fatality is escaped. All parts of the 
encephalon are subject to arterial disease and resulting hemorrhage, but 
certain locations present special liabilities. The most frequent site is in 
the distribution of the lenticulostriate arteries arising directly from the 

14 



210 DISEASES OF THE BRAIN PROPER. 

trunk of the middle cerebral and supplying the basal ganglia and their 
internal and external capsules. Of these, the anterior branch is the 
so-called artery of cerebral hemorrhage. After the region of the basal 
ganglia and capsules, in order of frequency as sites of cerebral hemor- 
rhage, follow the centrum ovale, cortex, cerebellum, pons, medulla, crura, 
and corpus callosum. So commonly, however, does hemorrhage occur 
in the neighborhood of the large ganglia that a somewhat definite clini- 
cal type of cerebral hemorrhage is presented. This will first engage 
our attention, and then the less frequent sorts and varieties, all of which 
have symptoms in common, may be rapidly sketched. 

Pathological Anatomy. — Cerebral hemorrhage of the capsular 
variety occurs with about equal frequency on the two sides of the brain. 
The quantity of blood extravasated depends upon two factors, (1) the 
size of the blood-vessel and (2) the arterial pressure, but the pres- 
sure is much the more important of the two. According to Wernicke 
"the apoplectic or traumatic effect is equal to the product of the 
amount of effused blood into the square of the pressure with which 
it is extravasated/ 7 Ordinarily the hemorrhage commences in the an- 
terior portion of the lenticular nucleus and separates or tears through 
the adjoining structures, invading the internal capsule, the external cap- 
sule, and the optic thalamus. It may extend upward into the centrum 
ovale or tear into the lateral ventricle, and finally break through into 
the pial spaces at the base near the optic chiasm. Very exceptionally 
the blood breaks through the cortex of the convexity, but ordinarily it 
is arrested at the lower surface of the gray matter. 

Recent hemorrhages show a coagulum bathed in serum and non- 
adherent to the surface of the hemorrhagic pocket. After a few days 
the serum is relatively increased, the coagulum is contracted, and is 
attached to the adjoining structures by fibrinous trabecular Absorption 
of the serum then follows. The clot is resorbed in part, and finally 
only an ocherous mass remains, made up of blood-crystals, pigment, 
and fatty detritus. By thickening and participation of the surrounding 
brain a sort of cyst is formed. If it is small and its walls coapt, 
cicatrization may ensue. About large so-called apoplectic cysts there is 
usually a zone of degeneration and fatty softening. This is often the 
seat of minute hemorrhages, and is likely to undergo inflammatory 
changes or by infection become purulent. An abscess thus results in 
wdiich, sometimes, the partially organized hemorrhagic clot floats. 

Even in recent hemorrhages there is difficulty in determining the 
origin of the blood. By carefully washing away the clot under water 
miliary aneurysms are almost certain to be found. They bead the 
arterial vessels that are brought to light, and sometimes one is fortunate 
enough to find the minute sac originally ruptured and still containing 
a fragment of organized clot. Other vascular lesions that occasionally 
give rise to cerebral hemorrhage are amyloid, hyaline, syphilitic, and fatty 
arterial degenerations and acute infective arteritis. [Not infrequently 
cerebral hemorrhage is secondary to a softening through which the artery 
is robbed of its proper support and nutrition. In ancient cases 
cicatrization and spreading degenerative changes usually obscure the 
exact vascular fault. 



CEREBRAL HEMORRHAGE AND THE HEMIPLEGIC STATE. 211 

The motor tracts that are cut by the lesion present a descending de- 
generation which extends downward the whole length of the neuron. In 
the cord the pyramidal tracts are usually both involved, but to a greater 
extent on the side opposite the lesion. Exceptionally in cases of long 
standing, changes in the upper motor tract entail secondary disturbance 
on the lower motor and trophic neuron, and an amyotrophic condition 
is superadded, with corresponding degeneration in the anterior horns. 

Etiology. — In any given case of cerebral hemorrhage there are, 
ordinarily, a number of causative elements. Almost invariably there are 
(1) high arterial tension and (2) lowered arterial resistance. The causes 
of miliary aneurysm are much the same as those of rigid arteries, 
atheroma, and cardiac hypertrophy. The strongly acting heart drives 
the blood-column through the rigid aorta and carotid, and its full force 
falls upon the arteries arising from the circle of AVillis. These are 
of comparatively small caliber, and, not having outlets by anastomosis, 
oppose a dead wall of resistance to the directly received cardiac impulse. 
Surrounded in turn by perivascular spaces and not supported by firm 
parenchymatous tissues, their walls weakened by age or infection and 
yielding at numerous points to the formation of saccular dilatations, 
arterial rupture naturally follows. 

The predisposing- causes of cerebral hemorrhage are those that pro- 
duce or tend to produce the primal arterial disease. Advanced age, 
gout, alcoholism, rheumatism, plumbism, and syphilis are chronic states 
favoring it. Acute infections, tending to produce acute arteritis or 
amyloid and fatty degenerations, such as puerperal infection, diphtheria, 
scarlet fever, etc., are possible active factors. Whooping-cough in chil- 
dren is an occasional cause, the factors of strain, infection and lowered 
resistance all being present. Ajq undoubted hereditary tendency to 
cerebral hemorrhage is sometimes encountered. The writer is familiar 
with one family of eleven brothers and sisters, nine of whom have 
died from cerebral apoplexy. The so-called apoplectic habit has no 
significance if not associated with other predisposing conditions. The 
relation of age to cerebral hemorrhage is an important one. During 
the first year of life it is relatively frequent, and drops thence to the end 
of the first decade. Gowers states that a proportion of 1.8 to every 1000 
under the age of ten have suffered from this accident. From ten to 
twenty-five it is infrequent, and then rapidly mounts, reaching its maxi- 
mum at about fifty-five, thence again descending, and seldom occurs after 
seventy-five years of age. The male sex shows considerable preponder- 
ance, about three males to two females suffering from cerebral hemor- 
rhage. This is due to their greater tendency to excesses and increased 
liability to exposures. Temperate climates and winter months show an 
excess of cases over the opposite conditions. 

Everything which induces an accelerated circulation must be ranked 
as an inciting- cause. All physical, mental, and moral shocks, and 
all intense emotions may lead to cerebral apoplexy in those predisposed. 
Muscular efforts, coughing, sneezing, straining at stool, coitus, and 
vomiting have induced it. Derangements of the circulation with cardiac 
effort, due to exposure to the cold or from a cold bath or a bath after a 
full meal, have served to rupture the diseased artery. In the Great Lakes 



212 DISEASES OF THE BRAIN PROPER. 

region of this country the frequent sudden changes in barometric pressure, 
attended as they very often are by extraordinary variations in atmospheric 
humidity and temperature, constitute a menace, if they do not furnish an 
inciting cause of cerebral hemorrhage. It often follows a debauch. 

Symptoms. — The onset of cerebral hemorrhage of the capsular 
variety is almost invariably abrupt, and constitutes the type of cerebral 
apoplexy that is familiarly and properly called " a stroke." In very 
exceptional cases it is preceded by momentary confusion, vertigo, un- 
easiness, or other vague subjective disturbance. Most of the alleged 
prodromata are merely symptomatic of the arterial condition that always 
precedes the stroke, and are common to peri-arteritis and arteriosclerosis. 
A hypertrophied heart, rigid artery, and high arterial tension, a con- 
tracted kidney and albuminuria, with or without formed kidney ele- 
ments, are of some value in presaging an apoplectic seizure from 
cerebral hemorrhage. The patient, ordinarily, is stricken down, 
and in the foudroyant cases may die instantly. If walking, he falls 
heavily, or if sitting, reels out of his chair. Consciousness is almost 
instantly abolished. The action of any of the inciting causes named 
above will correspondingly affect the opening scene. At first the face 
is pale, the pupils contracted, and muscular twitchings or, rarely, active 
general convulsions may occur. There may be considerable motor 
restlessness and uneasiness until coma becomes profound. 

In the apoplectic state that follows the patient lies inert, uncon- 
scious, breathing slowly and stertorously, and often presenting the 
Cheyne-Stokes respiration. The face is mottled or even deeply con- 
gested, covered with perspiration, and expressionless. The half-open 
eyes present sluggish or inactive and usually contracted pupils. The 
conjunctiva is usually congested and insensible, and the palpebral reflex 
is wanting. All forms of sensibility are abolished. The sphincters are 
relaxed and the limbs limp. There is usually urinary retention, and 
overflow occurs later. At this time it may be difficult to determine 
which hemisphere has been injured. Sometimes, by careful examina- 
tion, the paralyzed side is found more completely relaxed than the other, 
in which, perhaps, some slight resistance to passive movements is present, 
or the sound limbs when raised do not fall so heavily. There is also, 
even from the first, a tendency for the patient to direct his face and eyes 
in conjugate deviation to the side of the brain that contains the hemor- 
rhage. This indicates muscular paralysis on the side from which they 
are turned. This deviation must not be of the spasmodic sort, which has 
an opposite significance. Uhthoff 1 has found a choked disc in eleven 
per cent, of cases of cerebral hemorrhage, optic neuritis in six and a 
half per cent., and retinal hemorrhage in nearly three per cent. At 
first all the cutaneous and muscle reflexes are temporarily increased, but 
immediately subside and tend to disappear. The superficial reflexes, 
as a rule, are soon abolished on the paralyzed side. The unilateral 
absence of abdominal, cremasteric, plantar, and conjunctival responses 
furnishes important information in the early hours of the attack. The 
toe-sign of Babinski almost invariably develops on the affected side 
1 "Neurolog. Centralbl.," No. 20, 1909, p. 1106. 



CEREBRAL HEMORRHAGE AXD THE HEMIPLEGIC STATE. 213 

within a few hours, even within a few minutes, and persists indefinitely. 
The comatose condition either deepens into death or passes off. 

After a variable period of hours or even days the coma, in cases not 
immediately fatal, gradually yields to torpor, in which the patient can 
be partially roused by strong and especially by painful stimulation. He 
pushes away the pinching fingers of the examiner, mutters a little, takes a 
deep, quick inspiration, or otherwise manifests discomfort. Then he 
hears loud voice-sounds, and finally shows, by facial expression and 
attempts at speech, that he has regained partial consciousness. If undis- 
turbed, he relapses into stertorous sleep, and the expired air puffs out the 
flabby cheek of the paralyzed side of the face and escapes through the 
angle of the mouth on that side. Finally consciousness is restored. 

Shortly after the stroke the rectal temperature is slightly lowered, but 
is likely to rise a little above normal after a day or two. In all cases 
after a few hours the temperature will be found higher on the side from 
which the eyes are averted — that is, on the paralyzed side — than on the 
other. This is true of the mouth, face, trunk, and extremities, and the 
difference amounts to from 1° to 2° F. At the same time this warmer, 
paralyzed side often shows increased perspiration, and usually an in- 
tensified redness and congestion as compared with the other. 

The motor loss in this variety of cerebral hemorrhage is hemiplegic. 
After consciousness has partly returned its distribution can be plainly 

1 2 

I 

I w 

Fig. 85. — Right hemiparesis with athetosis in hand. 1, Ordinary expression ; 2, spasmodic involuntary 
laughter, showing bilateral action of facial muscles. 

determined. Usually the arm is much more affected than the leg, and 
the face shows great variations of implication in different cases. In some 
it is scarcely affected. As a rule, the distal portion of the limb is much 
more affected than the portion near the trunk. The hand thus suffers 
proportionately more than the arm or shoulder, the foot than the thigh. 
The muscles of the trunk, being paired and fully represented bilaterally 
in the cortex, do not show much one-sided loss of power. A careful 
examination will, however, detect reduced respiratory excursions on the 
palsied side in forced respiratory movements, and unilateral weakness in 
the acts of sneezing, coughing, etc. 1 The facial asymmetry offers several 
important and significant peculiarities. Except in the rarest instances it 
is only the lower half of the facial-nerve distribution that is much im- 
paired. The frontal and orbicular regions show but little lack of power; 
1 Sicard, "Arch, de Xeurolog.,*' Dec, 1899. 



214 DISEASES OF THE BRAIN PROPER. 

the brows are raised, the eyes close and open nearly as well as ever, but 
a slight unilateral paretic defect is certainly present as a rule. In the 
lower face the lack of muscular power and tone allows the mouth, chin, 
and even the nose to deviate to the sound- side. All voluntary attempts 
to use the labial, nasal, and zygomatic muscles increase the deformity, 
but usually in emotional expression, as in laughing or weeping, the lack 
of symmetry tends to disappear (Fig. 85). Only when the basal ganglia, 
and particularly the thalamus, are seriously invaded by the hemor- 
rhage do emotional expressions also intensify the one-sidedness. Even 
then the retention of power in the upper half of the face distinguishes 
this palsy from that of disease of the seventh nerve. The conjugate 
deviation of head and eyes passes away as consciousness returns, but 
the tongue when protruded usually turns strongly to the paralyzed side, 
owing to the weakness in the corresponding genioglossus. With the 
tongue protruded the patient cannot move its tip across the median 
line toward the sound side nor thrust it so strongly into the sound cheek. 
A deviation of the tongue to the same side is not a rare occurrence. 
Jones 1 has found it to be the case in over 10 per cent, of hemiplegics. 
This lack of muscular power in the tongue and lips tends to muffle and 
thicken the speech, which may even become nasal, as the soft palate 
shares in the muscular weakening and droops on the paralyzed side. 
Aphasia is not ordinarily produced by capsular hemorrhage. In ex- 
ceptional cases the lesion implicates the corticopeduncular speech- 
tracts, producing a variety of motor aphasia marked largely by ataxic 
control of the muscles of speech-production. 

Sensory Disturbances. — As consciousness returns after the stroke, 
ordinarily the complete cutaneous insensibility disappears. Only in 
those cases in which the lesion destroys the sensory pathway in the pos- 
terior third of the posterior limb of the capsule do we have persistent 
hemianesthesia corresponding to the hemiplegia. This identical anesthetic 
field is sometimes encountered in hysteria, which may indeed be induced 
by the shock of a cerebral hemorrhage as well as by any other accident, 
and may give rise to a perplexing combination. Close scrutiny for 
other evidence of antecedent hysteria should be made in all such cases. 
The sensory disturbance in the limbs is usually more pronounced toward 
their distal extremities, where the paralysis is also always most marked 
and persistent. Hemianopsia is frequently present immediately after the 
stroke, but usually passes away in a few days with the other sensory 
disturbances. When the visual path at the sensory crossway is injured, 
hemianopsia persists. Even when the patient is still inclined to stupor it 
may be detected by bringing the fingers into the visual field first from one 
and then from the opposite side. The ophthalmoscope frequently 
detects an engorged papilla due to the increased endocranial pressure. 
Disturbance of other special senses is subject to the same rule. Often 
there is considerable pain and sensitiveness in the paralyzed limbs. 
Severe headaches and vertigo are uncommon until the hemiplegic state 
is established, and even then they are rare. 

Trophic disturbance in the early days after cerebral hemorrhage is 
rare. An acute bedsore sometimes appears over the buttock of the 
1 "Jour. Nervous and Mental Dis., Oct., 1911. 



CEREBRAL HEMORRHAGE AND THE HEMIPLEGIC STATE. 215 

paralyzed side, and in a few days, almost in a few hours, attains large 
dimensions. Such cases almost invariably soon terminate in death. 
Rapid emaciation and even rapid fattening are encountered at times. 
Disturbance of the medullary nuclei probably accounts for temporary 
albuminuria and glycosuria, which are incidentally observed in some 
cases. To the same source some attribute the rare gastric and intestinal 
hemorrhages. Occasionally a large joint on the palsied side, notably the 
shoulder, may develop an acute arthritis, and all the articulations of the 
paralyzed limbs are later on inclined to rigidity out of proportion to 
their disuse. After the first week a rapid elevation of temperature is 
sometimes produced by the development of an infectious cerebritis about 
the hemorrhagic focus. It usually ends fatally. 

The hemipleg-ic state finds its prototype in the cases that survive 
the stroke of cerebral hemorrhage. It must not be overlooked that 
it is a sequence common to many cerebral and spinal lesions, and is 
associated with some neuroses. It may follow : (1) Traumatic lesions 
of the brain and cord ; (2) meningeal lesions due to hemorrhage, inflam- 
mation, syphilis, and tuberculosis ; (3) cerebral lesions due to hemor- 
rhage, softening, tumors, abscesses, and sclerosis ; (4) cerebrospinal 
lesions of tabes, multiple sclerosis, and general paralysis of the insane. 
It may be due originally to : (1) Intoxication by uremia, diabetes, 
alcohol, lead, mercury, and some carbon compounds ; (2) infections from 
pneumonia, malaria, typhoid fever, puerperal fever, eruptive fevers, 
diphtheria, influenza, syphilis, and tuberculosis ; (3) it marks some 
cases of chorea, hysteria, and paralysis agitans. 

In cerebral hemorrhage, if death does not occur during the first three 
weeks, improvement in the paralytic features uniformly appears and 
is progressive for several months. Finally, all gradations are encoun- 
tered, from the slightest paresis to complete hemiparalysis. In a well- 
marked case, in which at first the hemiplegia is complete, we may ex- 
pect some return of voluntary motion after ten or fifteen days. The 
lower extremity first shows improvement, and is followed by the face and 
later by the upper extremity. In six to eight weeks the patient may 
stand and perhaps with much aid walk a little. During this time a not- 
able change has appeared in the reflexes and the tone of the paralyzed 
muscles is greatly altered. At first the reflexes are abolished or greatly 
diminished and the muscles hang limp and flabby from the bones. Grad- 
ually the reflexes increase and become exaggerated. Transient stiffness 
and rigidity are then found in the limbs. Ankle-clonus, rectus-clonus, 
and even wrist-clonus appear, and with the temporary rigidities fore- 
shadow the later contractures. The increase in myotatic irritability may 
be expected to appear during the third week, and is always present sooner 
or later, if the motor pathway in the brain is injured by the hemorrhage. 

Introduced by the myotatic irritability, clonus, and the fleeting attacks 
of rigidity, the period of late contractures is established from one to four 
months after the stroke. In very rare cases it is never fully developed, 
and in other rare cases, owing to secondary changes in the trophic cen- 
ters of the cord, it disappears after being well marked for years and 
muscular atrophy develops, but the rule is that once present it is pro- 
gressive for a time and then permanently remains. Under the action 



216 



DISEASES OF THE BRAIN PROPER. 



of this contracture the limbs assume characteristic rigid attitudes that 
constitute great deformities. It sometimes strongly involves the face, 
which is then drawn to the affected side and gives to the sound side a 
false appearance of weakness. 

In the upper extremity the flexors predominate to draw the digits 
into the palm of the hand, to flex the wrist, to pronate the forearm, 
and to fix the elbow at an angle. The extremity is usually held close 
to the chest. In these vicious positions the joints become practically 
soldered. After the case is somewhat chronic, if the fingers or wrist 
are extended, they fairly snap back to their flexed positions, and the 
tightly clenched fingers may cause trophic lesions in the palm. In cases 
of long standing, probably both from the enforced inactivity and trophic 
disturbance, the range of joint movements is considerably limited irre- 
spective of the muscular contracture, and sometimes this appears early. 





I''" 



Fig. 86.— Contractured positions in hemiplegic hand. 

In the lower extremity extension prevails. The knee is held quite rigidly 
extended and there is a tendency to equinovarus, so that the foot rolls 
over on its outer border. These are the usual contractures, and give to 




Fig. 87. — The hemiplegic gait. 1 and 2, Advancing the hemiplegic leg in a circle from the hip ; 3, bear- 
ing weight on paretic leg and cane while advancing sound limb. 



the patient an attitude and a gait that are distinctive. It will be re- 
called that the distal portions of the extremities are most affected, and 



CEREBRAL HEMORRHAGE AND THE HEMIPLEGIC STATE. 217 

now, rigidly fixed by the contractures, they are moved en masse by the 
muscles of the pelvic and shoulder girdles. In walking the rigid lower 
extremity is used somewhat as a peg-leg. The body-weight is carried on 
the sound limb, over which die trunk inclines outwardly, and by body and 
pelvic movements the paretic lower limb is swung forward, the drag- 
ging toe describing an arc-like course around the heel of the sound side. 
Then upon the paralyzed limb, often trembling with clonic action, as 
upon a stilt, the next step is taken by the sound side, aided usually by 
a cane or crutch. When in the dorsal decubitus, the patient cannot lift 
the extended sound leg from the bed, though he may be able to lift the 
heel on the paralyzed side. This is due to the inability to fix the pelvis 
and the lower extremity on the affected side, which is necessary to rais- 
ing the opposite limb. 

A marked minority of cases show a type of extension in the upper 
extremity, which is most pronounced at the elbow. The limb is held 
rigidly by the side of the body. The wrist and fingers may, though 
very rarely, also be extended, and the supinators may overbalance the 
pronators. Again, flexion may predominate in the lower limb, or exten- 
sion may be present in the upper and flexion in the lower limb, or 
different segments of the same limb may show opposite conditions as to 
flexion and extension. This late rigidity may render it impossible to 
demonstrate the muscle reflexes, which, nevertheless, are greatly exag- 
gerated. The toe-sign is usually present and readily elicited. Like 
the myotatic irritability, the late contractures are due to the descending 
degenerative processes in the motor tracts. 

The paralyzed limbs show marked circulatory disturbance. They are 
at first reddened and cyanosed. The blanched spot caused by finger- 
pressure only slowly disappears. Sometimes they are sodden with per- 
spiration and show epithelial variations, either by increase or more often 
by decrease of growth in the nails, hairs, and epidermis. They are cold 
later on, and their temperature is reduced several degrees as compared 
with the sound side. At times there is marked edema, which may come 
on very early in the case, and is attributable to the muscular inactivity, with 
lymph-stasis, and frequently is associated with a kidney or cardiac lesion. 

A phenomenon is often noticed by hemiplegics that gives rise to 
false hope of returning voluntary movement in the paralyzed limbs. 
Sometimes without volition the paralytic hand may open or the leg 
draw up. These movements are perhaps analogous to the constant 
athetoid features that develop in some cases. The entire upper extrem- 
ity, over which the patient has practically no control, may execute such 
movements as raising itself over the head in conjunction with the other 
arm in yawning, stretching, or other instinctive act. These associated 
movements probably result from the bilateral ity of their cortical represen- 
tation. Again, if the hemiplegic attempts to write with the sound hand, 
provided it is the one not formerly used for that purpose, the paralyzed 
hand may sometimes be seen to duplicate the motions of the one volun- 
tarily used. Right-sided hemiplegics who are at the same time right- 
handed, in attempting to write with the left hand sometimes produce 
mirror writing, which is practically the normal method for left-handed 
individuals. 



218 DISEASES OF THE BRAIN PROPER. 

On the sound side there are also marked disturbances. The reflexes are 
exaggerated and even contracture may develop. The muscular strength 
is reduced from 10 to 50 per cent. Incoordination may be pronounced. 
Complications. — The hemiplegic state often presents sensory com- 
plications. Subjectively these consist in paresthesias, such as feelings 
of heaviness, dragging, and formication. Sometimes the limbs seem to 
the patient to be entirely gone; others complain of phantom or addi- 
tional limbs. According to von Bechterew, x lesions in the neighborhood of 
the lenticular nucleus are prone to produce this symptom, which he 
names pseudomelia paresthetica. Objectively we may have hemian- 
esthesia if the sensory portion of the capsule is injured, and the other 
sensory disturbances of injury to the great crossway may be added. 

A wide range of posthemiplegic motor complications are encountered. 
We find rhythmical tremors, as in hemiparalysis agitans, or the inten- 
tional variety of tremor, as in multiple sclerosis of limited distribution. 
Irregular movements, like those of chorea, ataxia, and athetosis, are 
quite common on the affected side. When they result from bilateral 
cerebral lesions, great diagnostic difficulties are presented. The pro- 
duction of all these posthemiplegic motor symptoms requires that the 
paralysis should not be complete, and their presence implies a condition 
of irritation somewhere in the path of the upper motor neuron. This 
is usually furnished by lesions in the region of the basal ganglia, especially 
those affecting the optic thalamus and impinging upon the capsular fibers. 

Among the trophic complications, in addition to the early, acute bed- 
sore, the paralyzed side may present indolent ulcerations over the 
sacrum, elbow, or heel. The amyotrophic disturbance already mentioned 
may come on within a few days of the stroke, or may appear late in 
the hemiplegic history, and, in either event, must be attributed to inter- 
ference with the trophic control of the anterior horns. The electrical 
reactions then vary from those of simple quantitative changes to the re- 
action of degeneration. This muscular wasting is most common in the 
upper extremity, and, when appearing early in the case, is of ominous 
import. The skin, hair, nails, and fatty dermal layers may be increased 
or more rarely diminished in the paralyzed limbs. 

It would also seem that dynamic, if not actual, changes in the an- 
terior horns must be accountable for the occasional acute hypertrophic 
neuritis that develops in the paralyzed limbs in the early days after the 
illness, and for the acute arthropathic affections that also appear at that 
time. These are sometimes associated. The diseased joints suggest 
rheumatism. They are inflamed, painful, hot. The joint-surfaces and 
novial organs rapidly disintegrate, and present practically the same con- 
dition as the arthropathies of tabes. When appearing early this joint 
affection is of bad import, like the acute decubitus and early amyotrophy. 

Hemiplegia from the ordinary capsular hemorrhage does not neces- 
sarily disturb the mind. In the old it may precipitate the mental de- 
terioration of senility, and it may be followed by organic dementia. 

The course of cerebral hemorrhage of the common type may 
present many variations. Death may occur almost instantly, but this 
is exceptional, and usually the result of inundation of the ventricles. 
1 "Neurolog. Centralb.," Sept. 1, 1905. 



CEREBRAL HEMORRHAGE AND THE HEMIPLEGIC STATE. 219 

Death may occur during the coma from the great size of the clot 
and the exhaustion of the patient. After coma has disappeared and 
before contracture has developed, death may result from cerebritis 
arising from infection of the clot. During this early period pneumonia, 
often caused by the aspiration of food or drink, sometimes carries off 
the patient. A succession of hemorrhages taking place at short inter- 
vals, one apoplectic phase succeeding another, are nearly always fatal. 
After the initial stroke, and usually before the termination of the coma, 
there may be a sudden increase in all the symptoms. The breathing 
becomes rapid, irregular, stertorous, the unconsciousness more profound. 
The reflexes, if partly present, are entirely lost, and tetanic spasms or 
convulsions appear on the paralyzed side. The temperature bounds 
upward and the case terminates fatally in a few hours, or in a day or two. 
These symptoms are due to the hemorrhage bursting into the ventricles. 
If the fourth ventricle is invaded, nystagmus appears and death promptly 
follows. In the so-called ingravescent apoplexy the hemorrhage begins 
without marked stroke, and, steadily continuing, produces the apoplectic 
state in the course of a day or two, finally inundating the ventricles and 
terminating fatally. 

Recoveries from cerebral hemorrhage are not rare, and in the 
majority of cases the hemiplegic state is reached and the stage of con- 
tractures is developed. Very exceptionally the hemiplegia practically 
disappears. This is only possible when the hemorrhage has affected the 
capsular tracts by pressure without producing rupture of their fibers, 
and then the clot is necessarily small. As the greatest rarity the re- 
covery may be so complete that no trace of the former palsy can be 
discovered by clinical examination. 

Clinical Forms. — Cerebral hemorrhage presents a number of clini- 
cal forms, the most usual of which has been the basis of the preceding 
description. Variations in localization and in the amount of ex- 
travasated blood endlessly modify the type. Within the field of the 
lenticulostriate arteries a very small hemorrhage may produce a partial 
hemiplegia or a monoplegia, though this is a rare form. We have the 
occasional form of hemiplegia with hemichorea, or hemiataxia, or hemi- 
athetosis. There is the form of hemiplegia with hemianesthesia and 
another in which hemichorea and hemianesthesia are combined. A rare 
form consists of a facial monoplegia with hemianesthesia, and a form 
presenting hemianesthesia and motor aphasia has been noted. Hemor- 
rhage into the posterior lobes of the brain is attended by the apoplectic 
onset or insult and leaves visual or aphasic remnants if it involves the 
corresponding radiations and pathways. In the anterior lobes and in a 
large portion of the centrum ovale a considerable hemorrhage may take 
place without producing lasting symptoms. In these hemorrhages re- 
mote from the capsule hemiplegic symptoms are sometimes present at 
first and then disappear as the traumatic effect of the apoplexy subsides. 
Primary cortical hemorrhage is exceptionally encountered. The clot is 
usually small, owing to the small caliber of the cortical arteries ; the 
stroke, therefore, is slight or absent, but stupor and semicoma may be 
present. The symptoms produced are those of an irritant lesion. If it 
occurs in the motor zone, repeated limited convulsions of a Jacksonian 



220 DISEASES OF THE BRAIN PROPER. 

type are likely to occur and may become generalized. Hemorrhages 
into the pons and medulla, if not immediately fatal, give rise to local- 
izing symptoms and cranial-nerve disorders that have already been dis- 
cussed, including the numerous crossed paralyses. 

Cerebellar hemorrhage usually presents a very sudden onset, but 
there is correspondingly much less disturbance of the mind and con- 
sciousness than occurs in the cerebral variety. The patient falls, 
vomits, and experiences intense vertigo. Attempts to sit or stand 
greatly increase the vertigo and vomiting and may render the horizontal 
attitude obligatory. If the lesion approaches the middle peduncle, forced 
movements or rigid positions may be induced. These may impel the 
patient strongly to the right or left, backward or forward, and in the recli- 
ning posture cause marked curving of the trunk in corresponding direc- 
tions. Ataxia and asthenia in the extremities are immediately produced, 
and tetanoid spasms may appear. Sensory disturbances are fleeting or 
absent. Later on the preponderance of symptoms is on the side of the 
lesion if it is unilateral, but if pressure occurs on the pyramidal tracts 
above the decussation, crossed symptoms are presented. Cranial-nerve 
impairment is likely to be present from irritation of the nuclei and 
pressure on the floor of the fourth ventricle may induce dangerous 
pneumogastric complications. Should this ventricle be flooded, bulbar 
symptoms are induced and death promptly follows. Much similarity 
is presented by attacks of labyrinthian vertigo, and at first the diagnosis 
may be impossible. A history of preceding attacks and of ear disease 
is significant. If the cerebellar hemorrhage involves the auditory 
nerve, the two symptom groups coincide. 

The diagnosis of cerebral hemorrhage is often difficult and some- 
times impossible. Its consideration falls into two parts : (1) The diagnosis 
during the apoplectic state and (2) the diagnosis after the apoplectic state. 

Shortly after the onset of the stroke we have to ask ourselves 
whether the case is one of syncope, poisoning, or alcoholic intoxi- 
cation. If one-sided symptoms can be detected, all of these conditions 
may be excluded, and each has some distinctive symptom that one on 
his guard may detect. The pale face, fluttering pulse, and sighing 
respiration of syncope, the contracted pupil of opium, the smell of 
alcohol on the breath, etc., are suggestive, and taken with the history 
of the onset, when obtainable, are nearly sufficient. But cerebral hemor- 
rhage may come on during drunkenness, or a hemiplegic case may be given 
stimulants. Uremia is more difficult to differentiate, and may occasionally 
counterfeit all the indications of cerebral apoplexy. Examination of 
the urine may throw light on the situation, but it is to be remembered 
that the conditions giving rise to uremia are those usually associated 
with arterial disease in the brain. Most uremic comatose cases, at some 
period, present vomiting, headache, motor excitement and spasmodic 
restlessness, in which paralytic features are lacking. The coma is rarely 
profound at first. Meningeal hemorrhage may be easily mistaken for 
cerebral hemorrhage, as stupor, coma, convulsions, and paralysis are 
produced by both. The meningeal form, however, usually follows 
injury, and comes on slowly or after a distinct interval. It is often 
marked by irritation of cranial nerves and early bilateral convulsions. 



CEREBRAL HEMORRHAGE AND THE HEMIPLEGIC STATE. 221 

The epileptic attack usually has a history of anterior convulsions, 
presents clonic, tonic, and stuporous stages, and is quickly and com- 
pletely recovered from. Attacks of focal epilepsy may indicate a cortical 
hemorrhage, but are common to all diseased conditions of the cerebral 
motor surface. Every case must be carefully analyzed, and often, even 
then, only a presumptive diagnosis can be finally reached. Hysteria in 
rare cases produces an imitation of cerebral hemorrhage that is ex- 
tremely faithful to the type. The attack, however, usually occurs under 
circumstances of emotional and psychical disturbances indicative of 
hysteria. The face is rarely involved, Babinski's toe-sign is absent, 
and sensory stigmata are commonly present. The age and clinical 
history are also significant. In general paresis apoplectiform seizures 
are common, and the differential diagnosis during the attack may be 
very difficult. A history of mental confusion, childishness of conduct, 
forgetfulness, unsteadiness upon the feet, and syphilitic infection would 
favor the paretic side of the question. Almost complete recovery from 
the stroke may then be expected in a majority of cases. 

After the early apoplectic symptoms have persisted many hours or 
have subsided, an organic lesion can usually be determined from the 
hemiparalytic features. The important question regards the nature of 
the vascular accident. Is it rupture or occlusion that has taken place ? 
Have we to do with hemorrhage or with infarction ? Are Ave in the 
presence of extra vasated blood with a tendency to encapsulation, or con- 
fronted by thrombosis, the precursor of softening ? It is a question 
of importance, both as to treatment and prognosis. It is sometimes an 
unsolvable problem, but should never be neglected. At the end of the 
next chapter a differential table is given, to which attention is now 
directed. In a general way we may say that the following points favor 
a diagnosis of cerebral hemorrhage : Sudden onset, absence of syphilis, 
and endocarditis, the presence of strong cardiac action comparatively 
early, high arterial tension, marked coma and cyanosis, lowered rectal 
temperature and raised unilateral temperature, convulsions involving 
the whole of one side, paralysis involving the whole of one side, early 
improvement in the paralysis most marked in the leg, lack of perma- 
nent sensory disturbances, the presence of complete hemianesthesia in 
the absence of hysteria, the development of postapoplectic tremor, and 
athetosis. In the early days of the apoplexy a retinal hemorrhage or 
blood in the spinal fluid offers very significant evidence. 

The topical diagnosis must follow the general considerations laid 
down in the discussion of the subject of cerebral localization. Atten- 
tion is again called to the fact that the above description is dominated 
by the clinical aspects of the usual capsular variety of cerebral 
hemorrhage. 

Prognosis. — A cerebral hemorrhage is always of serious import, as 
it is a conclusive demonstration of wide-spread and threatening arterial 
disease in the encephalon. However slight, it implies the probability 
of a recurrence. About two-thirds of all the cases survive the first 
attack, one-third the second, and very few the third. The size and 
location of the clot are important considerations. The prognosis is 
grave in proportion to the violence of the attack and the depth and 



222 DISEASES OF THE BRAIN PROPER. 

duration of the coma. Coma lasting three days seldom ends in recov- 
ery. The appearance of Cheyne-Stokes respiration or indications of 
Ventricular flooding practically mean death. The occurrence of con- 
vulsions is a serious feature. Pneumonia is almost invariably fatal. 
Acute bedsore and acute joint disease are usually followed by death. 
A recurrence of coma or a sudden elevation of temperature or repeated 
apoplectic features imply an early fatality. 

Unless there is some improvement in the paralysis at the end of the 
second week, it is likely to be permanent. The appearance of contrac- 
tures implies lasting functional loss wherever they develop. The state of 
contracture commences from twenty days to three or four months after 
the stroke. The shoulder and hip movements improve more than the 
knee and elbow ; the ankle and wrist, toes and fingers, progressively 
decline in recuperative prospects. The lower extremity surpasses the 
upper both in point of time and extent of recovery. Considerable 
improvement may be anticipated during the first two or three months, 
and then much slighter progress to the end of the first year or eighteen 
months. Thereafter the case will be practically stationary. The dura- 
tion of life among apoplectics is about five years, according to Dana, and, 
as he points out, a stroke may be a conservative measure, enforcing an 
inactivity that prevents arterial strain and thereby prolongs life. 

Treatment. — If a positive diagnosis of cerebral hemorrhage is 
made, immediate active treatment should be instituted, but in doubtful 
cases a masterly inactivity — an armed neutrality — is the proper course ; 
there are many who think it the only course. The important indication 
is to reduce arterial tension, to discount the pressure at the site of hem- 
orrhage. When the case is seen immediately after the stroke the head 
should be raised, an ice-cap applied, and faithful carotid compression on 
both sides of the neck employed for forty minutes. Meanwhile the 
blood should be directed to the lower extremities by having them swathed 
in hot compresses and by the intelligent application of mustard. Three 
drops of emulsified croton oil serve to practically bleed the patient 
into his abdominal vessels and at the same time unload the bowels. 
Regarding venesection, the forces are still divided. In plethoric, con- 
gested, livid cases with strong cardiac action it may properly be used. 
Aconite and veratrum are by some accounted equally valuable to 
bleeding, but they must be given in frequently repeated, competent 
doses. For instance, aconitia, -g-J-^- of a gr., or fresh Norwood's tincture 
of veratrum, two drops every twenty minutes until effects are produced. 
Bromids and ergot are only mentioned to be condemned. In some 
cases a failing heart requires active stimulation, and alcohol and strych- 
nin best serve the purpose. 

In most cases the hemorrhage reaches its maximum within three 
or four hours and the damage is done. Thereafter the indication for 
treatment is solely to prevent a recurrence, and that means to keep the 
arterial tension down. Quiet, warmth, liquid diet, if any, free bowels, 
cleanliness to prevent bedsore, the administration of cardiac sedatives ; 
attention to the bladder, which is likely to distend and overflow ; care 
to prevent aspiration pneumonia, from food, mucus, or a septic con- 
dition of the mouth, and readiness to meet recurrent hemorrhages or 



CEREBRAL HEMORRHAGE AND THE HEMIPLEGIC STATE. 223 

ingravescent apoplexy by carotid pressure will answer the major require- 
ment. Ligation of the carotid is not a well-established proceeding, 
and carotid compression must be used with circumspection and intelli- 
gence. In the aged and atheromatous it may produce convulsions or 
serve to increase the coma. The effect in controlling the circulation 
may be observed in the usually prominent and throbbing temporals and 
in the color of the face. Suggestions of early trephining and evacu- 
ating the clot have been made. If rupture of the motor path occurs 
directly the extravasation of blood takes place, further surgical lacera- 
tion can scarcely improve matters. If purulent cerebritis develop in 
the clot, trephining to drain such a focus may reasonably be attempted 
in this otherwise fatal complication. 

As soon as the apoplectic coma has passed away, gentle massage of 
the paralyzed side and exercise of all the paralyzed muscles by mild 
faradism should be instituted. The purpose should be clearly in mind 
to secure as much improvement during the first month as possible and 
to postpone to the utmost the appearance of contracture. A muscle that 
may feebly respond to volitional control, perhaps to the associated action 
of the sound hemisphere, is rendered perfectly useless by contracture. 
From the onset extremely gentle passive movements of all the joints to 
their full range should be employed every two or three hours. Every 
one is familiar with the rapidity with which muscular and joint stiffness 
appears in splinted extremities. In these hemiplegic cases the limbs are 
splinted by paralysis. As soon as there is any reappearance of volun- 
tary motion the patient should be encouraged to exercise it. These 
measures are usually postponed to the end of ten days or a fortnight in 
fear that, by instituting them early, the brain-lesion may in some way 
be increased. Certainly any violent or severe measure is most strongly 
to be deprecated, but a common-sense application of the foregoing direc- 
tions will be found to yield encouraging results. 

When contractures appear, every effort should still be persistently 
made to counteract their deforming effect. We are familiar with the 
vicious attitudes they produce. In the upper extremity the extensors 
should be encouraged by massage, electricity, and forced passive move- 
ments to overcome the usual flexor supremacy. Similarly, in the lower 
extremity the equinovarus should be overcome, if possible, by stimu- 
lating the antero-external muscles of the leg. Rigidity at the knee is 
less objectionable. Every additional week of suppleness may mean 
increased voluntary control. Xow, also, the patient should be constantly 
encouraged to concentrate his attention upon the paralyzed side and 
repeatedly attempt to move the paralyzed muscles, aiding the effort by 
the simultaneous use of the sound side in executing the wished-for 
movements. Weakness of the sound side may defeat efforts at walking, 
unless the patient is greatly encouraged and strongly supported. The 
distrust of their strength and preference for inactivity must sometimes 
be actively met by the encouragement and authority of the physician. 
After two years no further gain is to be expected, but even then loco- 
motion may be facilitated by orthopedic apparatus or by a tenotomy of the 
heel-tendon. There are very few hemiplegics who escape more or less 
persistent medication with iodid. Aside from syphilitic cases it can 



224 DISEASES' OF THE BRAIN PROPER. 

not be strongly urged. As a treatment of the basic arterial state, 
however, it often has a legitimate place, and therein may be prophy- 
lactic of a second attack of hemorrhage. Too often it seems to degrade 
the patient's general health without corresponding benefit. It should 
go without saying that general hygienic and tonic measures are always 
indicated. The enforced inactivity of the hemiplegic favors intestinal 
atony and cutaneous sluggishness, which require watchful and intelli- 
gent management. 

CHAPTER VII. 
CEREBRAL SOFTENING. 

The term " cerebral softening " is open to objection for several rea- 
sons, but usage has confirmed its rank. " Softening of the brain " is a 
lay expression usually applied to dementia, and based upon somewhat 
erroneous notions of the condition of the brain in such cases. By 
cerebral softening is here meant the retrograde process in vascular terri- 
tories of the brain, occasioned by arterial obliteration and local depriva- 
tion of blood-supply. It is an infarction process exactly similar to that 
which is common in the spleen and kidney. The brain-structure, how- 
ever is not of a uniform functional value, and a cerebral infarct in the 
majority of instances destroys specific brain-powers instead of simply 
reducing the capacity of the whole, as in the abdominal organs men- 
tioned. In addition it gives rise to secondary conditions similar to 
those following cerebral hemorrhage. It is to Virchow that we owe 
our first exact knowledge of the genesis of cerebral softening. Pre- 
viously the softened atrophic area was attributed to inflammation or some 
vague morbid process. We know now that the immediate cause of the 
encephalomalacia is the occlusion of the cerebral vessel that supplied 
the diseased portion. This obliteration of the lumen of the artery 
arises (1) from thrombotic obstruction developing on the site, or (2) 
from plugging by an embolus starting at a distance, or (3) from local 
thrombosis following the lodgment of irritant emboli. 

When a cerebral artery is occluded, the blood-supply of a tolerably 
definite territory is cut off because of the anastomotic defects of the 
cerebral circulation. In the case of a sizable vessel the center of its 
arterial field is wholly deprived of blood, but the margin is only rela- 
tively impoverished, as there is some overlapping of these vascular 
territories, by slight anastomoses and in some cases by direct anastomotic 
relations with the veins. The moment an artery is closed its distal 
portion is deprived not only of blood, but of blood-pressure, and, aided 
by its own resiliency, it tends to collapse. This gives opportunity for 
back pressure from the return or venous circulation, and the territory 
deprived of arterial inflow may become the seat of venous congestion. 
Moreover, the arterioles deprived of their nutrient contents are disposed 
to promptly degenerate, and thus arise the punctate hemorrhages so 
commonly found in comparatively recent cases of cerebral thrombosis. 
Subsequently, retrogressive changes take place looking to the removal of 
the mortifying focus. Fatty degeneration and phagocytosis go on rapidly. 



CEREBRAL SOFTENING. 225 

The coloring-matter of the extra vasated blood finally alone remains. 
Repair takes place about the focus of disease, and it becomes encapsu- 
lated. In some infarcts of minor size cicatrization ensues, and a scar is 
left to mark the location of the vascular lesion. 

Pathological Anatomy. — The first effect of arterial occlusion is 
to cause anemia in the distal portion, and the territory of distribution 
becomes blanched. The tissues degenerate, necrosis follows, and white 
softening is produced. If, from the return circulation and local punctate 
hemorrhages the strangled area becomes suffused and infiltrated with 
blood, color is added and red softening is presented. Finally, as resorp- 
tion takes place and degeneration becomes complete a yellow color from 
the remnants of the hemic pigment marks the softened and perhaps 
encapsulated tissue, giving rise to the name yellow softening. The three 
appearances are but stages of the same process, but white softening is not 
necessarily followed by the red and yellow changes. The red appear- 
ance, due solely to the hemorrhagic element, appears, if it appears at 
all, after a few hours or a few days, depending upon the activity of the 
venous back pressure and the degeneration of the arterioles. 

In a very few days after arterial obstruction has occurred the corre- 
sponding cerebral tissue presents a marked appearance of degeneration. 
It is a fact of practical bearing that nerve-cells, deprived of their 
nutritive supply for about forty-eight hours, are permanently ruined. 
The softening focus is infiltrated with serosity and the cellular and neu- 
roglial elements are already breaking up. The myelin separates into 
droplets and is rapidly taken up by migratory leukocytes, which attain 
large proportions and have by some been described as granular bodies. 
The degenerating focus shrinks and softens. If situated beneath the 
pia, the resulting depression is filled with a turbid, milky fluid, and the 
soft meninges are thickened and highly vascular. It becomes impos- 
sible to strip the pia from the gyri of the softened area without 
decorticating them. The cortex is pale and friable, the white substance 
softened often to diffluence. In old foci of softening the surrounding 
tissue is thickened, especially in its neuroglial makeup, and presents an 
indurated wall within which a yellowish fluid substance containing fat- 
crystals and amorphous matter represents the former cerebral structure. 
Yellow softening may be found at the end of six weeks, but is a feature 
of old lesions. These may even become calcareous. Cicatrization — the 
fibrous obliteration of small softenings — has been already mentioned. 
In some cases the softened focus becomes infected, as by an embolus 
from infectious endocarditis, or from pneumonia, or from any infection 
atrium, and a secondary true encephalitis is developed. This rapidly 
goes on to abscess formation, frequently with putrid, offensive, gangren- 
ous contents. Thrombosis occurring in the perforating arteries of the 
base, which are entirely without anastomoses, or in the deep cortical 
branches which penetrate the centrum ovale, produces rounded islets of 
necrosis, which in time may become encapsulated and contain only 
serous fluid. 

At the seat of arterial obliteration arising from local thrombosis we 
find, in recent cases, a partially or completely organized clot adherent to 
a spot or ring of endarteritis or atheromatous thickening. An embolus 

15 



226 DISEASES OF THE BRAIN PROPER. 

does not at first present adhesions to the intima. It may be made up 
of pure fibrin from the endocardium, or calcareous particles originating 
in cardiac or arterial atheroma. Hydatids, filaria, and any minute 
substance finding access to the blood-stream may furnish a cerebral 
embolus. In about nine cases out often the embolus originates in or near 
the heart, and in fortunate cases the exact location of its origin has been 
detected. Ordinarily an embolus lodges at the branching of an artery, 
from which point the thrombotic fibrin deposit extends. If the em- 
bolic mass be calcareous, it may abrade the intima and give rise to a 
dissecting aneurysm, which in turn leads to occlusion and thrombosis. 
The size of the softening depends entirely upon the size and relations of 
the occluded vessel. 

The location of cerebral softening is more frequent on the left than 
on the right side of the brain. The left middle cerebral is especially 
selected, and its perforating or basilar are more frequently involved than 
its cortical branches. This is due perhaps to the fact that cardiac 
emboli following the direct route tend to enter the vessels that most con- 
form to the straight line of their momentum. These are also the 
favorite seats of atheroma. The anterior capsulogangliar region is the 
most common site of cerebral softening, followed in decreasing frequency 
by the posterior capsulogangliar region, the cortical territory of the 
middle cerebral, that of the posterior cerebral, then that of the anterior 
cerebral. Softening is rare in the cerebellum and in the bulb, except 
in syphilitic endarteritis, which frequently implicates the brain-stem. 
In rare cases we encounter a bilateral and symmetrical softening. In 
some instances this may be explained by thrombosis or embolism start- 
ing in the circle of Willis. For instance, an atheromatous patch at the 
bifurcation of the basilar may furnish a plug to the left side, and circu- 
lation on that side being proportionately reduced, the next embolus goes 
to the right side. In some cases there are numerous foci of softening. 
Softening may aifect only the gray cortex, or the white subcortical 
substance, or both. The extent of necrosis depends always on the 
damaged arterial supply. If the Sylvian trunk be occluded, the entire 
sensorimotor zone is softened as well as the subcortical white substance 
as deep down as the basal ganglia. If the thrombosis or arterial stagna- 
tion implicates only the short cortical branches, local death of the brain- 
mantle alone may follow. Again, if the arterial disturbance affects the 
long penetrating arteries that traverse the cortex to supply the centrum 
ovale, the cortex may be spared. 

Etiology.— The ultimate causes of cerebral softening are those of 
the arterial diseases, already considered, that underlie thrombosis and 
embolism. In a rough way we may say that thrombosis, usually a 
sequence of atheroma and arteriosclerosis, pertains to advanced age, 
alcohol, lead, gout, and syphilis, and that embolism is an accident of 
left endocarditis due to acute rheumatism and the infections of pneu- 
monia, typhoid, diphtheria, the puerperium, etc. As a presumptive 
rule, we may also say that cortical softenings are commonly due to em- 
bolism and occur most frequently in youth ; that those of the central 
area are due to thrombosis and take place in advanced years. Throm- 
bosis is favored by a weak heart and sluggish arterial current of low 



CEREBRAL SOFTEXIXG. 227 

tension, conditions ordinarily found in cachectic and marantic patients 
and favored by sleep. Embolism is favored by any act that throws 
a load upon the heart and produces cardiac stimulation. Vigorous 
muscular efforts, sudden emotion, or merely rising to the feet from a 
reclining position may start an embolus when friable arterial or cardiac 
vegetations exist. Very exceptionally a cerebral artery is obliterated 
by conditions arising outside its lumen, as by a rapidly growing tumor 
or other compression factor acting with some degree of promptness. 
Unless the compression is brought rapidly to bear, the circulation is 
able to adjust itself. Heredity, sex, age, temperature, barometric 
pressure, and the seasons are of much less significance than in cerebral 
hemorrhage. 

Symptoms. — The early symptoms of cerebral softening are domi- 
nated by the rapidity with which the arterial current is blocked 
and by the importance and size of the vessel involved. As a matter of 
fact, embolism is capable of producing instantaneous blocking of the 
arterial lumen, and symptoms of great violence at the onset to some 
degree indicate embolism if hemorrhage is excluded. On the other 
hand, while thrombosis usually produces progressive symptoms, a slowly 
growing thrombic arterial lining may cause a sudden deposit of fibrin 
from the blood, and intense symptoms are thereby precipitated. Again, 
a small embolus may only partially choke the blood-current, and the 
slowly developing occlusion is marked by the deliberately advancing 
symptoms and prodromata of the stroke. Cerebral thrombosis, therefore, 
presents both (1) an abrupt and (2) a progressive onset, with different 
cerebral symptoms immediately resulting, but with the same terminal 
conditions. 

The Abrupt Onset. — With none or only momentary confusion the 
patient has a stroke or cerebral attack, followed by loss of conscious- 
ness, perhaps even by the development of coma. Hemiplegia develops, 
consciousness returns, and more or less paralysis persists. In about an 
equal number of cases consciousness is not lost, though the paralysis is 
as quickly developed, and, as a rule, the mental subjugation, the cerebral 
insult, is less than in hemorrhage. Many cases are attacked during 
sleep, and awake at their usual hour with no appearance of stupor and 
with their ordinary mental brightness. A very significant feature of 
thrombosis affecting the cortical circulation is the Jacksonian or limited 
convulsions which are commonly presented, and which tend to repetition 
during the early hours and days of the illness without great, often with- 
out any, disturbance of consciousness. Distinguishing softening from 
hemorrhage, we seldom encounter the retarded strong pulse, the subnormal 
temperature, the unilateral heat, the congested face, the respiratory diffi- 
culty, and the prolonged coma so characteristic of a ruptured cerebral 
vessel. In a fair proportion of all cases of thrombosis the early symp- 
toms are progressive. A monoplegia becomes a hemiplegia. Paralysis 
beginning in the leg invades the entire extremity, reaches the upper 
limb, implicates the face, disturbs speech if on the left side of the 
brain, and finally the hemiplegia is complete. This is due to the 
thrombus, by gradual increase, backing down the artery from its orig- 
inal place of development, and if it extend into the circle of Willis 



228 DISEASES OF THE BRAIN PROPER. 

the opposite Sylvian artery may also be blocked. When the basilar 
is invaded bulbar symptoms usher in a fatal termination. Thrombosis 
beginning in the branches of the middle cerebral may first produce an 
aphasia; lower facial paralysis and loss of power in the limbs of the 
same side may then be gradually added. The distribution of the 
arteries to the motor region makes clear the sequence of events. (See 
page 200.) 

The Progressive Onset. — AVhen the arterial obliteration is a slow 
process and the caliber of the vessel is gradually reduced, disturbances in 
the poorly irrigated cerebral district are likely to be manifested. In 
the case of a Sylvian vessel this is the rule. The patient complains 
of more or less transient or persistent sensations of fullness, heaviness, 
formication, weakness, pain, or other vague discomfort in the face or in 
one extremity, or merely in the distal part of an extremity. The face 
at the same time may show transient weakness, the leg may be dragged 
a trifle, and a little clumsiness may be noticed in the finer finger-move- 
ments. Speech very often is disturbed, presenting various slight aphasic 
indications. Any or all of these symptoms are likely to be most marked 
toward night or after fatigue. They indicate a local anemia of their 
respective cerebral mechanisms and a lowered nutrition that translates 
itself in paresthesias and paresis and foreshadows paralysis. In many 
cases the cortical irritation shows itself in twitchings in the face or in 
the extremities, or in a sudden thickness of speech. 

Groups of such symptoms may appear" several times, lasting at 
intervals for a day or two and then recede for weeks or months. 
Finally they return with more bruskness and severity, convulsions 
may ensue, the thrombosis is complete, and paralysis is permanently 
established. 

This progressive loss of cortical circulation is to some extent a 
part of the physiology of senile involution. The blood-current 
becomes gradually weaker and the arterial channels progressively 
diminish in capacity. The heart loses its force ; the fine, delicate, 
cortical vessels are most affected ; circulatory stagnation in the brain- 
mantle is favored, nutrition fails, psychical and motor and sensory 
functions are reduced in activity, and dementia is inevitable. In 
the brains of the aged, multiple foci of softening are commonly 
encountered. 

The paralytic state may thus be established suddenly with or 
without an apoplectic state, or may advance by steps and be pre- 
ceded by numerous warnings and significant symptoms. Softening 
once established has the tendency, as has already been indicated, to 
invade adjoining cerebral areas, related through the arterial supply. 
Hemiplegia and the hemiplegic state are common results. In cases of 
sudden onset, especially if marked by an apoplectic seizure, the hemi- 
plegia is usually complete and severe. In cases of less active onset, 
and especially in those of gradual development, the functional loss is 
less profound and there is a greater tendency to subsequent recession, 
leaving only a monoplegia or a monoparesis. The paralysis may be 
monoplegic from the first, and softening is the most common source of 
the cerebral monoplegias. In the same way aphasia alone may indicate 



CEREBRAL SOFTENING. 229 

the cortical disease. Persistent aphasia in all its varieties, nine times 
out of ten, is clue to cerebral softening. In the same way the cortical 
areas of half-vision may be destroyed, or any given cortical function 
may be singly selected for abolition. 

The paralytic state due to softening presents practically the same 
course and final deformities that mark it when resulting from cerebral 
hemorrhage (see p. 215). At first flaccid, the permanently para- 
lyzed limbs show increased reflexes after about three weeks, and the 
usual contractures are developed. If the paralysis in a given member 
remains unimproved at the end of the first week, it is likely to be 
permanent. The tendency to recession, to progressive improvement, is 
by no means so marked as in hemorrhage. While the traumatic shock 
to the brain is less, the destruction is relatively greater. 

Sensory disturbances, which in hemorrhage ordinarily disappear 
promptly, are commonly persistent in the paralytic state after softening. 
Their persistence indicates a cortical lesion unless hemiplegia and hemi- 
anesthesia coincide, when the sensory crossway is involved, whatever be 
the lesion, hysteria being excluded. The sensory disturbances, after 
cortical softening, are paresthetic, not anesthetic. This is due to the 
stratification of cortical function, sensation, muscular sense, and motion 
being represented at increasing depths in the sensorimotor zone, as 
described on page 168. That sensation is not abolished, but is only 
disturbed, is due to its probably complete bilateral representation in the 
hemispheres. 

Course. — As cerebral softening is a brain accident, the result of 
arterial disease, like hemorrhage, it may present all gradations of severity 
and extent and numerous clinical forms. Cases marked by abrupt onset 
with a well-marked apoplectic phase may sink into coma and die. In 
proportion as the onset is gradual the tendency to immediate death is 
lessened, excepting in those instances where progressive invasion of 
vascular territories shows that the thrombotic process is advancing 
toward the circle of Willis. The paralysis or aphasia once definitelv 
developed, there is still a tendency to improvement, which is less 
marked than in corresponding cases of cerebral hemorrhage. Should 
the softened focus become infected, an acute purulent encephalitis is 
likely to carry off the patient. This complication is marked by ele- 
vation of temperature, sometimes by somnolence, usually by convul- 
sions referable to irritation in or about the diseased area, and is fre- 
quently associated with a pneumonia or an acute bedsore. Months and 
years after the onset of the disease the softened focus still constitutes 
an irritant brain-lesion which may cause epileptoid convulsions. It 
may have a bad influence on the integrity of the mind and be followed 
by insanity. The hemiplegie state, when once developed, presents the 
common features and indications described in the preceding chapter. 
When multiple softenings occur, the clinical picture is much modified. 
A right facial paresis, with aphasic symptoms, may accompany a left 
brachial monoplegia. 

Diagnosis. — The diagnosis of cerebral softening often presents 
many difficulties and sometimes is impossible. In the great majority of 



230 



DISEASES OF THE BRAIN PROPER. 



cases, however, a careful scrutiny of all the data enables us to make a 
positive diagnosis, and in a fair share of the remaining cases a strong 
presumption can be established. The question primarily concerns the 
arterial occlusion. After the age of ten and up to forty a paralytic attack 
suggests embolism or syphilis. Endocardial disease, a recent history 
of acute rheumatism or infectious fever, speaks strongly for embolism. 
Practically a diagnosis of embolism can not be made in the absence of 
cardiac symptoms. After the age of seventy years the presumption is 
again in favor of softening, but from forty to sixty-five or seventy 
hemorrhage is the commoner cause of paralysis. A history of syphilis, 
plumbism, or alcoholism suggests softening. 

The mode of onset may clearly indicate softening. Prodromata and 
the gradual paralytic invasion, localized spasms, monoplegias, aphasias, 
and limited paresthetic areas are indicative of softening. The dispropor- 
tion between the paralysis and the apoplectic features suggests soften- 
ing. A complete hemiplegia of rapid development without a stroke can 
hardly be due to hemorrhage. A pale face, weak heart, normal temper- 
ature, and practically undisturbed consciousness all favor softening as 
the cause of a paralytic attack. Multiple palsies and bilateral palsies, 
especially if symmetrical, are usually due to softening. Softening occurs 
often during sleep and under conditions of low arterial tension, except 
in embolism. After the paralysis has been established it is likely to 
persist, though in children and young adults it may notably improve. 

Many of the clinical features of softening are produced by tumors, 
but ordinarily new growths have a more insidious course and present 
the cardinal symptoms of headache, vomiting, optic neuritis, and 
vertigo. Cerebral abscesses usually furnish a history or evidence of 
injury or otitis, but a softened area may be infected and break down 
into an abscess. It is with cerebral hemorrhage that softening is most 
confused. They have many common points. For instance, syphilis 
and alcoholism may cause both, and both have apoplectic onsets and 
paralytic sequels. In some instances the differential diagnosis can only 
be made out in the light of the subsequent course of the disease, and 
in a small number of cases it seems quite impossible to make it. The 
following table of probabilities will serve to show the direction a pre- 
sumptive diagnosis should take : 



Table of Differential Probabilities in Cerebral Hemorrhage and 

Thrombosis. 



Predisposing 
Conditions. 



Hemorrhage. 



Frequent before three years of 
age, and between forty and 
sixty. 



Peri-arteritis and miliary aneur- 
ysm the usual antecedent. 



Heredity often marked. 



Thrombosis. 



Common in old age and in young 
adults. 



Endarteritis, atheroma, endocar- 
ditis, and cachexia?. 



Heredity rare. 



CEREBRAL SOFTENING. 



231 



Table of Differential Probabilities in Cerebral Hemorrhage and 
Thrombosis. — ( Continued. ) 





Hemorrhage. 


Thrombosis. 


Inciting 
Conditions. 


High arterial tension. 


Low arterial tension. 


Excitement, effort, or shock. 


Rarely excitement or effort, ex- 
cept in embolism. Sleep favors 

it. 


Onset 
Conditions. 


No prodromata. 


Prodromata common. 


Sudden stroke usual. 


Complete stroke rare. 




Coma marked. 


Coma slight or wanting. 




Rectal temperature reduced, and 
surface temperature elevated 
on the paralyzed side. 


Temperature usually unchanged. 




Congested face ; respiratory diffi- 
culties. 


Pale face : no respiratory disturb- 
ance. 




Pulse slow, full, hounding. 


Pulse weak, soft, often rapid. 




Motor loss usually hemiplegic 
and fully developed at once. 


Motor loss often monoplegic and 
inclined to extend. 




General convulsions common. Limited convulsions common. 


Course. 


Rapid improvement in motion. 


Slow motor improvement. Ex- 
tension of paralysis often ob- 
served. 




Foot usually gains more rapidly 
than hand. 


Foot often gains less than hand. 




Anesthesia usually fleeting. 


Paresthesia persists. 




Persistent aphasia exceptional. 


Persistent aphasia and other cor- 
tical symptoms common. 




Postplegic athetosis, trembling, 
and chorea common. 


Postplegic athetosis, trembling, 
and chorea uncommon. 




Postplegic convulsions rare. 


Postplegic convulsions common. 




Spasmodic weeping and laughter 
common. 


Spasmodic weeping and laughter 
exceptional. 



Prognosis. — Cerebral softening is an accident following such a wide 
variety of diseases and conditions which provoke the endarterial process 
of thrombosis that prognosis can not be generalized. Every case has its 
own indications. The tendency to immediate death is less than in hem- 
orrhage, but the appearance of pneumonia, or an acute bedsore, or a 
sudden elevation of temperature, even of moderate degree, indicates a 
grave complication and a probable fatality. In embolic cases, if it is 
probable that the embolus is infected, as in infectious endocarditis, diph- 
theria, and the exanthemata, the outlook is much darkened by the 
probability of acute infectious encephalitis being set up in the softened 
area, to be followed by abscess and probably by death. Advanced 



232 DISEASES OF THE BRAIN PROPER. 

years are against the patient. In every case the prognosis should be 
held in reservation for a week until it is evident that the thrombosis is 
not spreading and that local infection has not occurred. The tempera- 
ture is here a valuable guide. Persistent severe convulsions commenc- 
ing early, perhaps present at the onset, are of grave significance. They 
point to involvement of the cortex and meninges on the one hand, or of 
the lateral ventricles on the other. The secondary implication of the 
meninges or ependyma over the softened area is usually limited, but in 
infected cases it may lead to a generalized inflammatory process of the 
utmost gravity. When the first fortnight has passed, the paralytic state 
may be considered established. Contractures and deformities are there- 
after developed, as in hemorrhage. The hemiplegic state presents nothing 
dissimilar to that following arterial rupture, and has been described in 
a previous chapter. The condition presented by a given case of 
softening at the end of the first month is likely to be permanent. This 
is especially true after middle life. There is also the possibility of 
epileptoid attacks following at any time, and the persistence of the 
endarterial disease or its generalized presence constitutes a continual 
menace. This is particularly true in multiple softenings and in the 
bilateral forms such as that which furnishes a pseudobulbar palsy. 

Treatment. — The treatment of cerebral softening to be efficient 
must antedate the occurrence of thrombosis. In a word, it must be 
prophylactic. In another word, it must be the treatment of the arterial 
disease. When the arterial current is cut off we yet have to deal with 
the basic disease in order to prevent an increase of the thrombus or its 
repetition and to cause, if possible, its diminution. When called at the 
onset of the softening in the early hours of the attack, if hemorrhage 
can be excluded, the treatment consists of maintaining a masterly inac- 
tivity. The patient's position should be horizontal, to favor the 
cerebral circulation ; the flagging heart may be encouraged with strych- 
nin and relieved with the nitrites given frequently, which also 
flavor increased circulation in the exsanguinated brain territory. The 
repeated use of normal salt solution by the bowel, or better by the 
hypodermic method, is often of great value. Small quantities of nour- 
ishment should be administered, and the functions of the bowels and 
bladder supervised. If hemorrhage cannot be excluded, the same 
course is still advisable, but if hemorrhage is diagnosed, the opposite 
plan of treatment for that condition, already described, should be insti- 
tuted. Purgation aud venesection cannot benefit a cerebral territory 
already exsanguinated. In cases of embolism, cardiac repose is to be 
encouraged that other particles may not emigrate. Bromid, to control 
the convulsions, may often be required. The further management of the 
case is that of good nursing. The arterial state must never escape atten- 
tion. Its amenability to treatment governs the outlook for the patient and 
the probability of recurrence. When the paralytic state is established, 
its management is the same as that laid down in the previous chapter, 
and for the terminal monoplegia or hemiplegia the indications are likewise 
identical. The treatment of aphasias and the development of the oppo- 
site-sided speech-centers have been described in the chapter on Aphasia. 



DISEASES OF THE CEREBRAL VEINS AND SINUSES. 



233 



CHAPTER VIII. 
DISEASES OF THE CEREBRAL VEINS AND SINUSES. 

Anatomical Considerations. — The blood entering the cranium by 
the internal carotids and vertebrals after irrigating the encephalon makes 
its exit mainly by the internal jugular veins. The return circulation 
from the ventricular portion of the cerebrum and the callosal portion 
of the hemispheres is by the Gallenic veins and inferior longitudinal 
sinus, all of which empty into the straight sinus. From the convexity 
the pial veins run upward and open into the superior longitudinal sinus 



Cornmunication, through, parietal 

foramen with external veins of skuU. 




Fig. 88. 



Ext. jugular vein 



-Diagram showing the communications existing between the superior longitudinal and 
lateral sinuses and the external veins, indicated in the figure by* (Leube). 



in a forward direction against the slow blood-current of this dural 
channel. Here the circulatory conditions are rendered still more 
unfavorable by hydrostatic pressure, by the presence of trabecule in the 
sinuses which impede the flow of blood, and by venous retardation 
during inspiration. The cerebellar veins empty mainly into the lateral 
sinuses. Into the dural sinuses also empty many veins from the face 
and scalp. The facial vein communicates with the cavernous sinus 
through the ophthalmic vein. The veins of the nasal vault open into 
the anterior extremity of the superior longitudinal sinus. Numerous 
veins of the scalp along the median line have a similar outlet. Veins 
from the mastoid process and its cutaneous surface enter the lateral and 



234 



DISEASES OF THE BRAIN PROPER. 



petrosal sinuses, and the occipital and posterior auricular veins are con- 
nected with the lateral sinus. In addition, many veins of the cranial 
diploe discharge into the sinuses. Finally, the sinuses connect with the 
veins of the spinal canal. 



Ant facial vein 




■Ext, jugul.vein 



Communication with veins 
at back of neck 



Fig. 89.— Diagram showing the communications existing between the lateral and cavernous sinuses 
and the external veins, indicated in the figure by * (Leube). 



The cerebral veins are subject to the same lesions that influence 
veins elsewhere, but we are only called upon to consider phlebitis and 
venous thrombosis. They are usually associated and, practically speak- 
ing, severe cerebral symptoms are alone produced by thrombi. Throm- 
bosis may occur in the pial vessels of the convexity and extend into 
the longitudinal sinus, or, beginning in the sinus, may invade the 
cortex and give rise to localized softening and focal manifestations. 
The entire subject may be conveniently described under the head of 
Sinus Thrombosis. 

SINUS THROMBOSIS. 
Intracranial sinus thrombosis occurs more frequently even than 
thrombosis in the pelvic veins, or in those of the lower extremities. It 



DISEASES OF THE CEREBRAL VEINS AND SINUSES. 235 

is favored by the sluggishness of the venous current and the other 
anatomical peculiarities above indicated. Septic invasion is also ex- 
tremely liable from the relation of these channels to the cavities of 
the nose, throat, and ear, and to the frequently traumatized surface of 
the face, neck, and scalp. It occurs in two forms, — the marantic and the 
infective. 

Marantic sinus thrombosis, or primary thrombosis, is a local 
condition occurring usually in the superior longitudinal, rarely in the 
lateral, and very rarely in the cavernous sinus. It occurs in debilitated 
states, and is most common at the two extremes of life. Exhausting 
diseases, weakness of the heart, and in general any cachectic state pre- 
dispose to it. Prolonged illness, as from diarrhea, typhoid fever, 
pneumonia, phthisis, cancer, malaria, the anemias, etc., often precede 
it. Under these conditions there is a tendency to fibrin deposit and 
thrombus formation which, once started, is likely to extend. Should it 
commence in a cortical vein, or extend from a sinus to the brain-surface, 
Jacksonian fits may be produced. 

Usually on post-mortem examination the thrombus is found to 
involve several sinuses and their tributary veins. When the entire 
lumen of a cortical vein is blocked, the drainage of its territory is pre- 
vented and localized edema, punctate hemorrhage, and red softening 
follow. In the same way edema occurs in the superficial parts of the 
face and head which drain into an occluded sinus. Swelling about the 
eye and exophthalmos, with retinal thrombosis and epistaxis ; swelling 
about the mastoid, over the vertex or occiput, is produced by the throm- 
botic closing of the sinuses respectively related to these regions. When 
the lateral sinus is involved, the thrombus may extend down the internal 
jugular and be found as a firm, palpable cord in the neck. In marantic 
thrombosis the clots are firm and non-adherent to the walls of the vein 
or sinus, — that is, they are not inflammatory. They tend to organize 
or resorb and do not disintegrate. Reestablishment of the circulation 
in the sinus is therefore possible, and usually takes place in long-stand- 
ing cases, but in cortical veins, if cerebral softening occurs, there is no 
tendency to circulatory restoration. 

The symptoms of marantic thrombosis are those of venous stasis, 
localized edema, and disturbed brain-function following upon exhausting 
diseases. As the longitudinal sinus is usually affected there is often 
epistaxis and disturbance in the leg-centers, indicated by weakness, 
tremors, paralyses, and spasms in the lower extremities. Convul- 
sions in children are commonly encountered, and may be limited 
or monoplegic when a cortical vein is invaded. Meningeal irri- 
tation often shows itself in rigidities, retracted neck, and vasomotor 
disturbance. 

The diagnosis of marantic thrombosis is usually obscured by the 
overshadowing picture of the preceding illness, and in those cases where 
external edema does not point the way it is rarely deciphered during 
life. There can be little doubt that it furnishes some of the cases of 
cerebral palsy in childhood. Convulsions coming on late in the history 
of exhausting illness, especially in children, should direct attention to 



236 DISEASES OF THE BRAIN PROPER. 

the possibility of sinus occlusion. If meningeal or focal symptoms are 
present, coupled with local edema about the eye or face, over the vertex, 
in the mastoid or occipital region, a diagnosis may be made. 

The prognosis will depend upon the nature of the initial illness, 
the probability of cortical softening, and the vital prospects. When 
the cachexia or exhausting disease can be controlled and life maintained, 
the tendency to resorption of the clot presents a favorable outlook, except 
for the softened areas of brain-tissue. When these have been produced, 
permanent disability of a motor or mental character, or both, may be 
expected. The treatment is that of the general condition. 

Infective sinus thrombosis, inflammatory thrombosis or secondary 
thrombosis, is the result of the invasion of pathogenic infectious organ- 
isms. It is, therefore, a secondary process and occurs usually in adults. 
Generally it is located in one of the paired sinuses and in the one nearest 
the infection atrium. It is likely to produce meningitis or give rise to 
cerebral abscess, or both, and it is frequently attended or followed by 
systemic infection and pyemia. It arises from septic traumatic condi- 
tions of the face, scalp, cranial and facial bones, and from septic pro- 
cesses in the nose, mouth, pharynx, in the various bony sinuses, and in 
the middle ear and mastoid process. By far the most common source 
of infection is suppurative middle-ear disease. Anthrax of the face and 
lips, facial and scalp erysipelas, dental caries, and carbuncles have been 
noted as causes. The sinus always becomes infected by extension of the 
septic process to it, either by direct invasion or by propagation along a 
venous tributary. Inflammation of the sinus-walls is followed by 
thrombotic coagulation of the contained blood, and a septic plug is 
formed that closely adheres to the diseased and softened vessel. 

The septic, soft, and disintegrating thrombotic clot, swarming with 
pathogenic and pyogenic bacteria, sets up infection of the immediate 
territory, and, yielding particles to the blood-stream, often induces dissem- 
inated and systemic infection. Thus arise the numerous pyogenic foci 
throughout the body that are frequently present. The thrombus once 
formed is prone to extend, and the internal jugular is often invaded, pre- 
senting itself in its upper third as an indurated cord that can be palpated 
in the neck. Even the superior vena cava has been invaded. The 
sinus-walls being softened, the neighboring leptomeninges are infected 
and a localized or disseminated septic meningitis is added. In a similar 
way the infective process travels along the veins into the substance 
of the encephalon and sets up abscesses. Macewen thus tabulates 
the principal differences between marantic and infective sinus throm- 
bosis : 

Sinus Thrombosis. 
Marantic. Infective. 

1. Chiefly affects the longitudinal si- 1. Chiefly affects the paired sinuses. 

nuses. 

2. The clots tend to organization or are 2. Clots tend to purulent disintegration. 

absorbed. 

3. Hemorrhages into cerebral cortex in 3. Hemorrhages into brain or cerebel- 

about half the cases. lum seldom occur. 



DISEASES OF THE CEREBRAL VEINS AND SINUSES. 237 

4. Tendency to produce brain softening. 4. No tendency to brain softening. 

5. There is seldom purulent infection as 5. Purulent infection common from 

a sequence. septic or infective emboli. 

6. No accompanying leptomeningitis, 6. Often coincident purulent leptomen- 

cerebral or cerebellar abscess. ingitis, cerebral or cerebellar ab- 



The symptoms of infective sinus thrombosis are local and sys- 
temic. The local ones are due to circulatory disturbance, such as cir- 
cumscribed edema and brain symptoms. They will be given in detail 
in the description of thrombosis of special sinuses. The systemic 
symptoms are those of septicemia ; intense headache, often localized at 
the seat of disease ; vomiting, fluctuating and remittent temperature ; 
small, thready pulse ; leucocytosis ; rigors, profuse perspiration, dry 
tongue, anorexia and diarrhea, or constipation. 

Depending upon the preponderance of symptoms and their grouping, 
the septicemia shows different clinical varieties. When the lungs are first 
or mainly involved by the plugging of pulmonary vessels, localized or 
diffuse pain is occasioned, cough is induced, and the expectoration may 
change to "prune-juice" appearance, and then becomes purulent, fetid, 
and extremely offensive as the pulmonary process increases. Abscesses 
form and gangrene occurs. In this way septic pneumonia also is 
induced. 

When the brunt of the attack falls upon the abdominal organs, the 
typhoid type of septicemia, which closely mimics enteric fever and is 
sometimes mistaken for it, is presented. In another and much smaller 
group of cases meningeal symptoms dominate the picture and are 
actually due, in large part at least, to the infective leptomeningitis. 
All three of the symptom groups, or any combination of their various 
features, may be presented by the same case. 

Infective cavernous sinus thrombosis arises from septic invasion, 
reaching the sinus usually by Avay of the ophthalmic vein. It may also 
be due to a forward extension of a septic process in the lateral or petrosal 
sinuses. The secondary meningitis to which it gives rise is basilar. 
Fractures of the cranial base and blows on the head have furnished its 
starting-point. Erysipelas of the face, especially about the eye and 
nose ; abscess of the orbit ; infections of the nasal, buccal, and pharyn- 
geal cavities or of their sinuses ; ulceration of the tonsillar glands, and 
caries or periosteitis of the facial, especiallv of the maxillary bones, have 
led to it. 

Symptoms : One sinus is usually first involved, and the local 
manifestations are one-sided. There is, however, a pronounced ten- 
dency for the process to invade the opposite sinus, and then the case 
presents bilateral signs. Such a sequence is highly diagnostic. The 
first affected side may even show improvement through the establish- 
ment of the collateral return circulation before the second side is 
invaded. There is usually considerable pain of a supra- or infra-orbital 
neuralgic sort, and diffuse headache. Mental symptoms are wanting, 
unless meningitis is set up, and then delirium, hebetude, and coma may 
appear. When the sinus is plugged the return circulation through the 



238 DISEASES OF THE BE A IN PROPER. 

ophthalmic veins is cut off. The orbital contents become edematous, the 
ocular globe is thrust forward, the lids are swollen, and the swelling ex- 
tends to the nose, broAV, and cheek. There may also be swelling on the 
same side of the pharynx. The optic disc is congested or choked, the 
retinal veins are distended, and pressure is exerted on the ocular nerves 
that enter the orbital apex. This causes more or less ophthalmoplegia. 
The third, fourth, sixth, the ophthalmic division of the fifth, and the 
optic nerves are more or less affected. Ptosis, strabismus, pupillary 
stasis, and defective vision in varying degrees are thereby added to the 
exophthalmos. 

The invasion may be abrupt or insidious and the disease may last 
from a few days to several months, but infective cases are practically 
fatal. When the second eye is involved, it usually is very rapidly 
affected. The appearance of basilar meningitis and the development 
of septicemia add immediate gravity to the already serious condition. 

Infective lateral sinus thrombosis is the form most frequently 
encountered. Its origin is nearly always in a septic condition of the 
middle ear. The petrosal sinuses and the internal jugular are usually 
invaded. It is commonly encountered in young adults, and is rare in the 
two extremes of age. While ordinarily due to middle-ear disease, it may 
arise from a mouth or throat infection by way of the Eustachian tube 
and tympanum, from extension of thrombosis in other sinuses, from 
basilar fractures involving the petron, and from infections about the 
occiput, nucha, and mastoid. 

Symptoms : The lateral sinus is usually affected from a chronic 
middle-ear suppuration which has caused more or less erosion of the 
tympanic bony structure. An acute process may cause it, but this is 
exceptional. In the chronic cases of purulent otitis media it is a con- 
stant menace. Frequently there is a lessening or cessation of the 
ear-discharge, pain develops in the ear, and headache follows. The 
fluctuating temperature mounts up, and vomiting and rigors indicate 
the involvement of the sinus or an intracranial extension. Local signs 
of lateral sinus thrombosis depend on the obstruction of its lumen and 
the location or extent of the thrombus and phlebitis. Occlusion of the 
sinus, blocking the inlet of the mastoid vein, gives rise to a circum- 
scribed edema extending from the auricle over the mastoid. Pain on 
percussion of the mastoid is present only w T hen the bone or periosteum 
is inflamed. If the thrombosis is situated lower in the sinus and shuts 
off the condylar veins, through which the superficial circulation of the 
lateral lower occipital region drains, a brawny hardness and edema may 
be made out in the upper part of the posterior cervical triangle. Should 
the phlebitis extend into the internal jugular, extreme local tenderness is 
found over the upper portion of this vessel on palpation, or may be 
experienced by the patient in swallowing. The head is usually inclined 
to the affected side to lessen muscular pressure on the jugular. When 
the thrombosis follows down into the jugular, it may be easily palpated 
as a firm, cord-like structure. Disintegration of the thrombus may 
cause it to disappear in a few days. The lymphatic glands in the neck 
are frequently engorged and easily palpable. Gerhardt has pointed out 
that during inspiration the external jugular vein on the affected side is 



DISEASES OF THE CEREBRAL VEINS AND SINUSES. 239 

less prominent. This is due to the occlusion of the internal jugular, 
which allows rapid drainage of the external branch into the common 
trunk. If, however, the thrombus extends into the common trunk, the 
external vessel is then engorged and more prominent than on the sound 
side. 

If the inflammatory thickening at the jugular foramen is sufficiently 
great, it involves, by extension or pressure, the cranial-nerve trunks, 
which make their exit at this opening. Pneumogastric, spinal accessory, 
and glossopharyngeal symptoms are then produced. Respiratory, laryn- 
geal, cardiac, and vocal disturbances ; difficulty in swallowing, spasm 
or paresis in the sternomastoid and trapezius point to this condition. 
Abscesses sometimes form in the neck, under the sternomastoid or in the 
nuchal region. 

Almost from the first there are distinct cerebral symptoms. The 
cephalalgia is attended by somnolence, which may deepen into coma. 
Delirium is often an early symptom. Phlebitis is likely to extend into 
the temporosphenoidal lobe and cerebellum, giving rise to diffuse inflam- 
mation or rapidly producing softening and abscesses. At the seat of 
the sinus thrombosis the softened dural wall no longer protects the soft 
meninges, and a localized septic meningitis, with a tendency to become 
diffuse is occasioned. Even the bone under the sinus is eroded, and defi- 
nite discolorations are left, both on the cranial wall and on the cerebral 
surface, to mark the site of the sinus disease. 

A disease presenting so many complications and possibilities neces- 
sarily lacks clinical uniformity. While lateral sinus thrombosis is 
usually confined to one side, it may propagate itself into the venous 
channels of the opposite side and infect both internal jugulars. The 
appearance of cerebritis, meningitis, or intracranial abscess greatly 
reduces the life chances. Septicemia is particularly likely to develop, 
with its own serious import. The virulence of the infection, however, 
seems to vary between wide extremes. Some cases run a rapid course 
to fatal termination in four to seven days, others last weeks and months, 
and exceptional ones may recover. The gravity of the disease can not 
well be overestimated. 

Infective thrombosis of the longitudinal sinuses is extremely 
rare, while marantic thrombosis finds its most common location in these 
venous passages and especially in the superior one. Infectious condi- 
tions in the nasal vault, in the scalp, and in the cranial diploe of the ver- 
tical region are capable of extension to the superior longitudinal sinus. 
Phlebitis may then extend to the cortical veins. Occlusion of the sinus 
leads to local edema in the scalp and probably in the brain also, but the 
collateral circulation obviates any serious results from this mechanical 
feature. The danger lies in the likelihood of septic cerebral phlebitis 
and septic meningitis. Usually the obtrusive meningitic features pre- 
dominate, and suggestions of cortical phlebitis and even of abscess for- 
mation are obscured or overlooked. 

The treatment of infective cranial sinus thrombosis is primarily 
surgical. The infection atrium is to be determined and rendered 
thoroughly aseptic. Whenever possible, it must be eradicated. In the 
case of the cavernous sinuses little more can be done by the surgeon, 



240 DISEASES OF THE BRAIN PROPER. 

but Dwight and Germain 1 have reported one instance in which the 
cavernous sinus was reached surgically with immediate improvement in 
the patient's condition, though with fatal termination ultimately. A 
previous case by Hartly was entirely successful. Aggressive inter- 
ference is allowable, and indicated when the lateral and longitudinal 
sinuses are invaded. Many cases of lateral sinus thromboses have 
probably been saved by prompt and radical interference. The sinus 
has been opened, the infective thrombus removed, and abscesses in the 
temporal lobe and in the cerebellum drained. Often as a preliminary 
measure the mastoid antrum and the middle ear have been surgically 
dealt with, but when there is evidence of sinus thrombosis it is a waste 
of time and opportunity to stop at this step. 

Local applications of heat and cold to the head may be used, and 
serve sometimes to relieve the headache and modify the delirium. In 
view of the septic nature of the disease, supportive measures are emphat- 
ically indicated from the first. Against the septicemia we may bring 
measures to bear that favor elimination by the skin, bowels, and 
kidneys. The administration of antiseptics, such as the salicyl pre- 
parations and the mercurials, are of doubtful value, but are strongly 
advised by many and should not be omitted. In protracted cases 
autogenous vaccines may be of service. 



CHAPTER IX: 

CEREBRITIS, ENCEPHALITIS, AND ABSCESS OF THE 

BRAIN- 

Inflammation of the brain proper may be local or generalized, 
acute or chronic. 

Acute Localized Cerebritis. — Etiology. — The brain is subject to 
inflammatory processes the same as any other parenchymatous organ, 
yet generalized cerebritis is rare, and only recently have we learned to 
recognize it. Localized acute cerebritis, on the other hand, occurs with 
frequency, but is practically, if not invariably, a secondary condition. 
Meningitis always entails some underlying cerebritis. A circumscribed 
cerebritis occurs about a hemorrhagic focus or spot of thrombotic softening 
if infection is added. Without the additional infection such as is fur- 
nished by septic endocarditis or other infective focus the zone surround- 
ing a cerebral tumor, hemorrhage, or area of softening is one of conges- 
tion, edema, and pressure necrosis. Blows on the head may cause 
localized meningitis and cerebritis at the point of violence, or on the 
opposite side of the head by the action of contre coup. In some cases 
the local cerebritis alone follows, and this may only affect the white 
matter below the cortex. Apparently the traumatism favors the local 
action of bacteria by reducing the resistance of the tissues, as proved 
by Ehrnrooth in an interesting series of experiments. 2 Cranial frac- 
tures, punctured wounds, and perhaps severe concussion may cause it. 
Bone disease, septic processes in the diploe, and in the cranial bony and 

1 " Boston Med. and Surg. Jour.," 1902. 2 " Rev. Neurolog.," Aug., 1900. 



CEREBRITIS, ENCEPHALITIS, AND ABSCESS OF THE BRAIN. 241 

venous sinuses, may lead to cerebral inflammation, and be followed 
by abscess. Infection of the brain after operations sometimes causes a 
diffuse cerebritis that may involve an entire hemisphere. Hernia cere- 
bri is generally a manifestation of a septic inflammatory process. Sim- 
stroke, heat-stroke, and alcoholism seem capable of inducing cerebritis, or 
at least of so modifying the cerebral nutrition that dementia may follow 
and sclerotic brain-tissue be found postmortem. To Van Giesen we owe 
a knowledge of the cellular changes following insolation and their prob- 
able relation to an acute auto-intoxication. 

In certain conditions the inflammation falls on definite cerebral struc- 
tures. In this way arise the clinical symptom groups described under 
the terms acute polio-encephalitis superior and acute polio-encephalitis in- 
ferior, when the cranial nuclei are invaded in the upper or lower groups, 
furnishing acute nuclear ophthalmoplegia in one instance and acute bul- 
bar palsy in the other. These have already been described with the 
diseases of the cranial nerves. (See page 157.) Striimpell alleged an 
acute inflammatory process in the cellular cortex, especially of the motor 
regions, analogous to that of poliomyelitis as the explanation of many 
cases of cerebral palsy in children. To this he applied the term polio- 
encephalitis, a name given also to the inflammations of cranial-nerve 
nuclei, making an additional adjective necessary. It is, therefore, 
sometimes called polio-encephalitis anterior or corticalis. All of these 
polio-encephalitides are analogous to the spinal form or identical with 
it and often clinically associated. 

The pathological anatomy of the various conditions which have 
been assembled under the head of acute localized cerebritis shows at first 
a high degree of vascular engorgement, edema, and punctate hemorrhage. 
The inflamed tissue presents above the level of the surrounding part, 
and is often slightly softened. Its reddish color and yielding consist- 
ency have led to its description as a red softening. It has much the 
macroscopical appearance of embolic red softening, with which it was 
long confused. Leukocytal infiltration of the brain and the disintegra- 
tion of neuroglia, myelin, and nerve-cells may induce a pultaceous and 
even creamy consistency. A nidus ripe for infection is formed, and when 
this occurs abscess formation is prompt. Later on, if not infected, there 
is usually more or less shrinking of the inflamed mass, absorption of the 
necrosed elements, proliferation of the connective tissue, and sclerotic 
thickening which may reach a leathery toughness. Small foci may in 
this way become cicatrized. Finally, after years, it may be impossible 
to say whether inflammation, hemorrhage, or thrombosis was the initial 
feature of the cerebral defect. 

Symptoms. — The indications of acute localized cerebritis are 
obscure. Often associated conditions, such as meningitis, overshadow 
it in the clinic. Whatever be the seat of the cerebral inflammation, 
there is usually headache, sometimes vomiting, and rarely optic neuritis. 
Delirium or somnolence may be present or may alternate. Involve- 
ment of special sensory or motor convolutions or pathways gives rise 
to localizing features marked by defect or disturbance of function. 
The clinical picture, therefore, always strongly suggests meningitis, 
in 



242 DISEASES OF THE BRAIN PROPER. 

and the treatment and prognosis are practically the same as in that con- 
dition. 

Acute Hemorrhagic Encephalitis. — Striimpell, in 1889, and 
shortly afterward Leichtenstein, in 1890, called attention to cases of 
diffuse hemorrhagic encephalitis. In 1895 Oppenheim 1 reviewed the 
literature of the subject, pointed out the intimate relation of the disease 
to Wernicke's polio-encephalitis superior and to StrumpelPs polio-en- 
cephalitis anterior, and added six cases, several of which recovered. 
Other cases have been reported by Furbringer, Putnam, Freyhan, 
Neuwerk, and Brie, all of which are quoted by Putnam. 2 Brie 3 
has since reported a second instance, with full autopsy and bacteriolog- 
ical investigation. There can be little doubt that numerous cases have 
been mistaken for meningitis. Anatomically the disease is marked by 
multiple, non-suppurative, inflammatory foci showing congestion and 
punctate or massive hemorrhages, leukocytal infiltration, and localized 
destruction of brain-tissue. 

Etiology. — Regarding the causation of acute hemorrhagic encepha- 
litis there is much to be discovered. Most of the reported cases followed 
influenza. Putnam's last case followed the mumps, and erysipelas, 
diphtheria, typhoid, typhus, and malaria 4 have been followed by localized 
hemorrhagic encephalitis. The writer has seen two cases after in- 
fluenza, one after pneumonia, and one with some unknown infection 
associated with acute nephritis. It is a matter of speculation whether 
various infections act locally or by their elaborated toxins. Southard 
and Keen 5 found the staphylococcus aureus in five of six fatal cases in 
man, and experimenting on guinea-pigs, produced similar brain lesions 
by inoculations with pure cultures of this bacterium. An interval, a 
sort of incubation period, is often noted between the infectious disease 
and the manifestation of the cerebral symptoms. Children and young 
adults furnish most cases. 

Morbid Anatomy. — The meninges commonly are normal in appear- 
ance. There is usually some increase of cerebral fluid, and the ventricles 
may be largely distended by blood-tinged contents. The choroid plexuses 
and the vessels generally are engorged. Scattered throughout the brain, 
but principally in the white matter of the hemispheres and in or about 
the basal ganglia, are foci of hemorrhagic, softened, infiltrated brain- 
tissue. In some instances the hemorrhage is massive, in others there is 
but a slight hemic coloring. Microscopically the blood-vessels are 
found distended, the lymphatics filled with blood-cells and leukocytal 
elements, and at various points they are ruptured into the surrounding 
brain-substance. 

The influenza bacillus has sometimes been found in these foci, 6 
and there are some who think the process may originate in bacterial 
embolism. 

1 "Deut. Zeit. f. Nervenheilk.," Bd. vi. 

2 "Jour. Nerv. and Ment. Dis.," Jan., 1897. 3 "Neurol. Centralbl.," No. 1, 1897. 

4 Dana, "Medical Record," July 7, 1900. 

5 "Amer. Jour. Med. Sci. " March, 1905. 6 Putnam, loc. tit. 



CERE BRIT IS, ENCEPHALITIS, AND ABSCESS OF THE BRAIN. 243 

Symptoms. — The symptoms of acute primary hemorrhagic enceph- 
alitis are not definite, and commonly suggest meningitis. A preceding 
acute infection may be followed immediately or after several weeks by 
headache, hebetude, vomiting, convulsions, or localized palsies. Slug- 
gish pupils and squints are rather common. Sleepiness that tends to 
coma is usual, and rigidity of the neck has been repeatedly observed. 
The pulse may be slow, the temperature elevated, normal, or subnormal. 
The palsies, which may be multiple, declare the localized processes 
and have a tendency to vary in intensity from day to day. Pulse and 
respiration become shallow and frequent, the stupor deepens, bedsore 
may form, and death terminate the case in a few days or in several 
weeks. A fair proportion of cases, as insisted upon by Oppenheim and 
others, recover, almost, if not completely, after a tardy and anxious 
convalescence. 

It will be seen that the disease is clinically obscure and the diagnosis 
has usually been made post mortem. During life it is usually confounded 
with meningitis. This is not of great practical moment, as the treatment 
is the same. The prognosis is grave, but rather more favorable than the 
early descriptions indicated. Gradual onset, comparative mildness of 
symptoms, and long duration of disease have a favorable import. 

Chronic cerebritis, and chronic encephalitis are terms loosely applied 
to late and usually secondary conditions that are mainly sclerotic and 
degenerative in nature. This sclerosis may exist in disseminated 
patches or in large, circumscribed areas ; it may involve an entire hemi- 
sphere or be largely confined to the gray matter of both half-brains. 
The portion of the encephalon thus affected is disturbed in its function, 
which is usually greatly impaired or entirely abolished. 

Abscess of the Brain. — Brain-abscess is always secondary, and is 
due to the invasion of pyogenic bacteria. 

Etiology. — In a rough way we may say that all the causes of infect- 
ive simts thrombosis and acute localized cerebritis are competent to pro- 
duce brain-abscess, as the first step in its development is inflammation. 
Suppurative middle-ear disease furnishes almost two-fifths of the cases, 
and head injury about one-fourth. About one-sixth of the cases are 
due to general pyemic states. Of this number purulent pulmonary 
diseases furnish the great majority. Septic inflammation in the nasal 
and pharyngeal spaces, brain-tumors, infected cerebral hemorrhages, 
and infarcts furnish a small contingent. In rare cases the oi'dium albi- 
cans has been found in the abscess and traced through the blood-vessels 
into the nose. In others the only pathogenic bacterium present is the 
tubercle bacillus. Actinomyces have also been encountered. Males 
are about three times as subject to abscess of the brain as females, and 
five times as frequently affected with the traumatic variety. More than 
half of the cases occur between ten and thirty years of age. Koerner 
states that in Prussia about five per cent, of all deaths between the ages 
of ten and twenty are due to cerebral complications of otitis, mainly 
abscesses. 

Pathological Anatomy. — The most common seat of brain-abscess 
is in the temporosphenoidal lobe, due, doubtless, to the relation of the 



244 DISEASES OF THE BRAIN PROPER. 

venous circulation of this part of the brain and of the middle ear with 
the petrosal sinuses. In decreasing frequency follow the cerebellum, 
the centrum ovale, the pons, the occipital lobes, the parietal lobes, and 
the frontal lobes. The invasion pathway is often obscure, but the arterial 
route has been demonstrated in some instances, the perivascular spaces 
in others. The common sequential relation of middle-ear disease, sinus 
thrombosis, and brain-abscess calls attention at once to the venous chan- 
nels as entry- way for the pyogenic bacteria. The extension of cere- 
bral phlebitis from a sinus thrombosis was repeatedly mentioned in the 
preceding chapter as inducing cerebral softening and abscess formation. 
Frequently the abscess is single and of a size varying from a pea to a 
hen's egg or even to a larger size. In the regions of latent lesions, 
especially in the frontal and occipital lobes, an abscess may attain very 
large dimensions and contain many ounces of pus. Very commonly 
multiple brain-abscesses are encountered. In ear disease, abscesses, both 
above and below the cerebellar tentorium, are generally encountered, 
and failure to explore the cerebellum after the evacuation of an abscess 
in the temporal lobe has lost lives. When the infection arises from 
purulent lung disease or septic endocarditis, the left side of the brain is 
more affected for the same reason that embolism favors the left hemi- 
sphere. Under these circumstances, and in the case of infection from 
typhus, enteric fever, and other general pyemic states, numerous small 
abscesses may be found. In this way the brain may be fairly riddled 
with multiple abscesses. Relatively the gray matter of the brain is less 
liable to abscess formation than the white substance, and the cortex is 
often preserved over an extensive underlying abscess. Rarely a fistulous 
tract communicates with diseased bone, or reaches the outer surface of 
the cranium, or discharges into the nasal fossae. On the other hand, no 
connection may be discernible between the infection and the abscess. 
The pus varies with the nature of the infection and the age and char- 
acter of the abscess. In some recent cases it merely saturates the soft- 
ened tissues ; in others it is encysted ; in a third variety an encysted 
old abscess is found floating in a secondary, surrounding, more recent 
abscess, the walls of which are made up of infiltrated, purulent, softened 
brain-tissue. In the old cases the pus is thick, yellowish or greenish, 
and in about a third of them extremely fetid and offensive. Some- 
times it is reddish from the admixture of blood. The pus-corpuscles 
and leukocytal elements vary according to the age of the lesion. The 
streptococcus is usually found, but pneumococcus, staphylococcus, 
bacillus pyocyaneus, bacillus tuberculosis, and the bacteria of various 
mixed infections have been noted. 

The majority of abscesses are encysted. When located near the 
surface, the meninges may form part of the containing wall. A begin- 
ning cyst- wall has been noted as early as the thirteenth day. Its 
thickness and consistency increase with age. It is made up by a pro- 
liferation of the neuroglial tissue and the fibrous structures of the 
brain. Usually delicate, in some instances it forms a glistening, resist- 
ing membrane of almost a horny consistency, and it may even calcify. 
The brain-tissue surrounding an abscess is usually more or less softened, 



CEREBRITIS, ENCEPHALITIS, AXD ABSCESS OF THE BRAIX. 245 

and if infected rapidly breaks down, leaving the old abscess-cyst afloat. 
Rupture of an abscess by its steadily increasing contents, which is the 
usual ultimate accident, inundates the brain-tissue or breaks into the 
meninges, setting up a purulent process, or floods the ventricles and 
promptly terminates life. 

Symptoms. — The symptoms of brain-abscess are usually indefinite, 
often very obscure, and sometimes entirely unnoticed by patient and 
physician. Different cases present the widest variety of clinical phases, 
depending upon the virulence of the infection, the rapidity of abscess 
growth, the location of the process, and the complications. Some cases 
run a rapid course to a fatal termination in a few days, and others pre- 
sent a latent period that may last months and even years, to end with 
rupture and death. We may, in some cases, make out three stages, — one 
of invasion, one of remission, and a terminal one of paralytic features. 
In other words, one of cerebritis, one of encapsulation and latency, and 
one of rupture, infection, meningitis, or ventricular inundation, and 
death. 

The invasion stage presents the obscure picture of encephalitis. 
There is a low febrile movement marked by a vacillating temperature, 
which sometimes has a distinctly subnormal tendency, with a slow pulse. 
An intense and persistent headache lasting days, taken with the tem- 
perature, suggests meningitis. The headache is often circumscribed and 
may correspond to the location of the abscess, but as frequently is felt 
at a distant point. Rigors and profuse sweats indicate the septic char- 
acter of the disease. A varying degree of leukocytosis is frequently found. 
Vomiting and constipation or diarrhea are often present. Papillitis or 
optic neuritis only rarely occurs. The mental state is one of torpor and 
indifference, or delirium maybe present and the sharp "hydrocephalic" 
cry may be uttered. This stage lasts from two to ten days and may 
pass at once into the third stage or be followed by a remission. 

The remission stage is gradually established by the subsidence of the 
disturbances that appear in the period of invasion. The headache, 
fever, vomiting, and mental irritation almost disappear or entirely cease. 
Occasionally the improvement is very prompt and complete. A latent 
period is thus produced that may extend almost indefinitely. The 
gradual increase in the size of the abscess and its encapsulation gives 
rise to very little disturbance. Its effect is that of a foreign body^ and 
its presence is marked by much less disturbance than attends the growth 
of a solid tumor. At times there may be intense headache, vomiting, 
and even convulsions. An occasional temperature, or a tendencv to a 
remitting temperature, sweats, and emaciation may show the hectic state 
and alone indicate the ever-present danger. 

The paralytic stage is the usual termination of brain-abscesses that 
have presented a period of latency or remission. It is of sudden onset, 
and rapidly runs its course within a few days. It not infrequently 
promptly follows the invasion period, and the fatal mechanism is 
usually the same in both. In some cases this consists of a rupture of the 
abscess, causing a rapid infiltration of the cerebral capsule; an invasion 
of the medulla; a tearing through the cortex, setting up a purulent men- 



246 DISEASES OF THE BRAIN PROPER. 

ingitis; or the inundation of the ventricles. There remain, however, 
a large number of cases in which these anatomical conditions are want- 
ing to explain the sudden onset of this stage. Ordinarily an apoplectic 
stroke, with or without convulsions, takes place. Usually there are no 
premonitions or only the vague indications of cerebral mischief which 
have presented at intervals during the latent period. The apoplectic 
coma may be punctuated by Jacksonian fits, marked by conjugate devia- 
tion of head and eyes and some lateral weakness, and the patient may 
succumb in a few hcurs without regaining consciousness. Death, 
indeed, may be sudden. If the immediate effects of the stroke subside, 
a hemiplegia with marked rigidity, and often with spasmodic features, 
is progressively developed. The headache, the fever, and the symptoms 
of the early stage reappear or become intensified. Nystagmus, pupillary 
inequalities, and involvement of the ocular muscles appear and death 
is likely to follow, preceded by delirium and coma. 

The localizing symptoms of brain-abscess are rarely prominent. 
Usually they are quite indefinite or entirely lacking. The location is 
often in the frontal, temporal, and occipital lobes, or in a cerebellar 
hemisphere, whence focal symptoms do not arise. As a rule, an abscess 
of the brain, due to disease of the cranial bones, lies subjacent to the 
original lesion. In the same way ear disease gives rise to abscess near 
the petron, but in rare instances the purulent collection has been found 
at a considerable distance, and even in the opposite half of the brain. 
Abscess due to embolic process from the heart or lungs is likely to be 
located in the capsular or Sylvian arteries, and gives rise to early hemi- 
plegic features or disturbances of the motor cortex. The circumscribed 
headache sometimes furnishes a localizing feature, but it can not be 
relied upon. Macewen has noted a higher percussion note over the 
abscess than was yielded by the rest of the head, and Dana has con- 
firmed this symptom in one case. Local tenderness and increased 
temperature may occasionally be made out. When the abscess is asso- 
ciated with septic sinus thrombosis, we have, in addition, the local super- 
ficial evidence of that disease. Even when the sensorimotor zone is 
invaded, the symptoms may be very slight. Abscesses may, however, 
yield as definite localizing features as any other encephalic lesion, and 
these then have the significance and value discussed under the head of 
Cerebral Localization. Involvement of cranial nerve-trunks, cerebellar 
symptoms, hemianopsia, Jacksonian fits, aphasias, and other localizing 
indications should always be carefully sought. Multiple abscesses also 
lead to symptoms of corresponding diversity. 

Diagnosis. — The diagnosis of cerebral abscess depends very largely 
upon the history or presence of trauma or of an infective condition about 
the head and face or in the thorax. A chronic otorrhea, maxillary ab- 
scess, ozena, sinus suppuration, or purulent pulmonary disease, followed 
by headache, vomiting, delirium, stupor, slow pulse, vacillating tempera- 
ture, and rigors, means encephalic invasion. These symptoms are 
common to meningitis and abscess, and the differential diagnosis can not 
always be made. Any evidence of a circumscribed process, however, 
favors the idea of abscess, and hence localizing symptoms become very 



CEREBRITIS, ENCEPHALITIS, AND ABSCESS OF THE BRAIN. 247 

important. The two conditions are often associated and a terminal 
suppurative meningitis is common in abscess. In latent periods the 
differentiation of cerebral abscess from a growth may be impossible ; 
nor is it essential. The terminal stage, with its rapid onset and para- 
lytic features, may readily be confounded with cerebral hemorrhage or 
softening if it occurs in middle life and is preceded by apparent health. 
When systemic sepsis is manifested, the purulent character of the en- 
cephalic process is less doubtful. A marked leukocytosis is of important 
diagnostic and prognostic significance. 

Abscesses resulting from ear disease, bone disease, and disease about 
and in the facial cavities — in other words, abscesses due to direct invasion 
— are ordinarily single. Abscesses resulting from pyemic states and from 
purulent thoracic conditions are usually multiple. Cerebellar abscesses 
are also usually multiple. The localizing diagnosis is made on the lines 
already laid down in Chapters III and IV of this part. 

Prognosis and Treatment. — Suppurative disease within the 
cranium is always grave. Although a cerebral abscess may encapsulate 
and lie dormant for years, this can not reasonably be expected to take 
place, and even when it does, it constitutes a constant menace to life. 
Encapsulation does not necessarily check suppuration, and eventual rup- 
ture or secondary infection is the legitimate sequel. The late results 
are ordinarily fatal, and latent cerebral abscesses account for a certain 
proportion of sudden deaths. 

The treatment of cerebral abscess should be prophylactic. Chronic 
suppurations in ear and nose should never be neglected and the utmost 
precautions should be taken, in the management of all wounds about the 
head and face, to prevent infection and sepsis. From these largely 
controllable sources the great majority of brain-abscesses and other en- 
docranial suppurations arise. When the diagnosis is established, there 
should be immediate recourse to surgery. Of all encephalic diseases 
abscess promises the best results to surgical measures. Adequate drain- 
age after opening the skull has been followed by brilliant success in 
numerous cases and in the hands of many operators. All other meas- 
ures are inadequate. 



248 DISEASES OF THE BRAIN PROPER. 



CHAPTER X. 
THE CEREBRAL PALSIES OF CHILDREN* 

A number of varied developmental and acquired cerebral defects 
result in paralysis in childhood. They involve or destroy within the 
cranium some portion of the upper motor neuron, and give rise to clini- 
cal types that justify a separate description. Their importance and fre- 
quency have been recognized only within a feAV years, but it is now 
appreciated that in the early years of life cerebral palsies are fully 
as common as the spinal variety. Etiologically, they may be divided 
into three groups : (1) Those due to prenatal conditions; (2) those fol- 
lowing birth accidents, and (3) those dependent upon disease or trauma 
after birth. Clinically, we also divide them into those showing uni- 
lateral defects, the hemiplegic cases, and those presenting bilateral 
defects, the diplegic cases. 

Etiology. — One of the most important prenatal conditions resulting 
in infantile cerebral palsy is an actual deficiency of brain elements, a 
true agenesis. This may be marked by convolutional simplicity and a 
lessened number of cortical cells and pyramidal fibers. In other cases 
a part or the whole of a hemisphere, or of both hemispheres, may be 
lacking. Between these gross teratological defects and a condition in 
which the neuron units have diminished dynamical qualities or a less- 
ened power of endurance, that in early life leads to their atrophic or 
sclerotic degeneration there is but a difference of degree. The lack of 
constitutional endurance, of capacity for growth, and of resistive power 
underlies many brain and cord diseases that present hereditary and 
familial characteristics. In other instances it furnishes a lowered re- 
sistance to toxic influences. In given cases unfinished children, lack- 
ing motor elements in the cortical mantles, and children born prema- 
turely, before the pyramidal apparatus has been well established, present 
various degrees of motor and cerebral defect. The upper motor neuron 
is well formed only at the ninth intra-uterine month, and not com- 
pletely developed until the second or third month after birth. Much 
defect in the upper neuron is always marked by spasticity and impaired 
motility in the muscles supplied by the lower or terminal motor 
neuron. 

Rarely direct traumatism has affected the brain of the unborn child 
which presents hemiplegic contractures at birth. In other cases evidence 
of hemorrhage and softening has been found, and in many instances the 
probability of a prenatal meningo-encephalitis has been upheld by the 
presence of localized and diffuse sclerotic changes in the brains of new- 
born children. Inherited syphilis and toxic conditions due to illness 
of the mother have been accused in some of these cases. Porencephalia 
is usually due to intra-uterine disease of the cerebral vessels. 

The conditions attending birth frequently lead to brain-lesions 



THE CEREBRAL PALSIES OF CHILDREN. 249 

in the child. The great majority of cerebral birth palsies occur 
in protracted labors, and consequently in primiparse. A number of 
them follow precipitate labor and in both are due to violent compression 
of the fetal head. Comparatively few can be attributed to the use of 
forceps, and it is exactly in these cases that the labor is likely to have 
been tedious. Forceps accidents, however, can not be denied or over- 
looked, and the misuse of these powerful instruments is fraught with 
serious results to the skull and brain of the child. The facts, however, 
favor earlv skilful instrumental interference as compared with tedious 
labor. 

The frequency of hemorrhage into the cerebral and spinal meninges 
during birth has been put on a sound foundation by the investigations 
of Litzmann, McXutt, and Spencer. It is found in the great majority 
of stillborn children and is the common cause of asphyxia of the 
newborn. Occasionally this blood comes from a ruptured longitu- 
dinal sinus, but most frequently from the pial vessels. Punctate and 
larger hemorrhages within the substance of the brain and cord are fre- 
quent. The results of these birth hemorrhages depend upon the quan- 
tity and location of the effused blood. "Where death does not follow, all 
degrees of disability are encountered. Palsies follow the involvement of 
the motor cortex or its pyramidal tracts, but if the frontal lobes are seri- 
ously affected, idiocy is a consequence and is a frequent accompaniment of 
motor disturbance. Similar disturbance of the latent lesion territories 
of the brain may give rise to insignificant or very obscure symptoms. 
As a rule, the hemorrhage is basilar in location in vertex presentations 
and vertical in breech cases. The absorption and organization of these 
hemorrhages lead to a more or less diffuse sclerosis of the brain-substance 
that inhibits its growth and diminishes its functional capacity. In 
other cases in terminal stages large areas of softening and cyst-like 
formations are found that are indistinguishable from porencephalia. 
In about one-fourth of these cerebral birth hemorrhages the spinal cord 
is similarly affected. Some cases of syringomyelia may have this origin. 

The postnatal causes of cerebral palsies in children, according to 
Osier's list, are hemorrhages, embolism, endo- and peri-arterial changes, 
encephalitis, and cerebral venous thrombosis. In other words, they are 
the same as in adults, but hemorrhage is more frequent than thrombosis. 
The relation of acute infectious diseases to embolism and arteritis only 
needs to be recalled. Traumatism and tumor formation cause some 
cases. Of encephalitis much has been said, and Strumpell claimed 
cortical polio-encephalitis to be the lesion in many of these cases, but 
the exact pathological process still escapes us owing to the paucity of 
early post-mortem examinations. Cerebritis in infancy and childhood 
is a more frequent occurrence than formerly supposed. The lesion is 
often primarily vascular. Gowers was the first to insist on the part 
played by venous thrombosis, and others, among them Osier, have 
added weight to the contention. This cerebral venous thrombosis is 
often a part of sinus thrombosis, to which it may hold a primary or 
secondary relation. It serves to produce softening, and sclerotic changes 
in the cortex and palsies follow. As many of these palsies start with 
convulsions, the question arises whether the convulsion is the cause or 



250 



DISEASES OF THE BRAIX PROPER. 



effect of the lesion. It may be either. There can be no doubt that the 
increased arterial tension of the convulsed state may cause rupture of 
cerebral vessels, but, as a rule, the convulsions are due to the irritant 
effect of the lesion. Later on epileptic or epileptoid convulsions are 
very commonly encountered. Sex plays no etiological part. Males and 
females are about equally affected. One-half the postnatal cases in 
children occur within the first three years of life. 

Morbid Anatomy. — The post-mortem findings in these cases furnish 
various lesions. Sachs gives the following table : 



Classification of Ixfaxtile Ceeebkal Palsies. 



Groups. 



Morbid Lesiox. 



I. Paralysis of intrauterine 
onset. 



Large cerebral defects, porencephalia. 
Defective development of pyramidal tracts. 
Agenesis corticalis, highest nerve-elements involved. 



II. Birth palsies. 



Meningeal hemorrhage, rarely intracerebral hemor- 
rhage. 
Later conditions : Meningoencephalitis chronica, 
sclerosis and cysts, partial atrophies. 



III. Acquired palsies. 



Hemorrhage, meningeal and rarely cerebral. 

Thrombosis, from endarteritis, and in marantic con- 
ditions. 

Embolism. 

Later conditions : Atrophy, cysts, and diffuse and 
lobar sclerosis. Meningitis chronica. Hydro- 
cephalus seldom the sole cause. Primary en- 
cephalitis and the polio-encephalitis corticalis 
acuta of Striimpell. 



The difficulty of deciding the origin of the terminal conditions is 
very great and it is often impossible. Porencephalia, for instance, may 
be due to defective development, to embolism, to thrombosis, or to hem- 
orrhage. The initial process of a diffuse sclerosis may be hemorrhagic 
or inflammatory. 

Symptoms. — The clinical history of cerebral palsies in children 
varies in the three sets of cases. In the prenatal cases the condition is 
congenital, but may not be noticed for some time after birth. In birth 
palsies the condition is usually noticed shortly after birth or develops 
within a few weeks. In the later-acquired cases the patients may pre- 
sent an ordinary record up to the onset of the paralytic features. In 
their final development all present very common attributes and are 
usually indistinguishable by external examination alone. The great 
majority of natal and prenatal cases have bilateral palsies. After birth 
the tendency is to one-sided paralysis and after the age of three it is 
almost the invariable form. A pure monoplegia is so extremely un- 
common as to be almost unknown. 

Hemipleg-ic Cases. — The hemiplegic cases are the best type for 
study, as the unaffected side furnishes an opportunity for comparison. 
Ordinarilv the paralytic features develop after an acute febrile attach, 
after or during an acute infectious fever, or in marantic states. The 



THE CEREBRAL PALSIES OF CHILDREN. 251 

child is seized with convulsions, which are more severe on or entirely 
confined to one side of the body and to the side that is afterward para- 
lytic. The convulsive attack is usually prolonged, lasting for several 
hours or even for a day or two, and perhaps returns several times 
within a few days. During the eclamptic seizures the temperature 
mav be markedly elevated and more or less unconsciousness is commonly 
present. The child is left weak and exhausted, often with continued 
feverishness, and the loss of power on one side is frequently only 
incidentally noticed. If the child had formerly spoken, speech, as 
a rule, is temporarily lost, whether the paralysis be left- or right- 
sided, but after the age of about six years aphasia is well marked 
only in lesions of the left side in right-handed children. If their 
intellectual faculties are not destroyed, speech even then is regained 
with surprising rapidity. 

The paralyzed limbs soon develop marked spasticity with exaggerated 
reflexes, which the spasticity may conceal unless the examiner be atten- 
tive to the play of tendons when the tests are made. The spastic con- 
dition is also followed by contractures which place the limbs in the posi- 
tions so characteristic of hemiplegia in adults. Here also are similar 
attitudes and gaits. 

Sensory disturbance is apparently absent even in the recent cases, and 
electrical reaction modifications are never present. The trophic condition 
of the paralytic limbs, however, is reduced, as is shown in the unequal 
growth on the two sides as time goes on. This results in some deformity. 
The shoulder girdle is smaller on the affected side, the chest and arm 
less in size, and the pelvis and lower extremity unequal to corresponding 
parts of the sound side. The half of the head and face on the paralytic 
side may be of inferior dimensions. The limping gait of hemiplegia is 
increased by the shortened limb, the pelvis tilts, the spine becomes 
scoliotic, and the retarded, paralytic, contractured upper member is held 
to the side of the body and usually flexed in all its joints. 

From nine months to two years after the paralytic onset the para- 
lyzed side, especially the hand, in over one-half of the cases, is animated 
by automatic and involuntary choreoid or athetoid movements, which often 
attain a wonderful complexity and range. They may also involve the 
face, but seldom to the degree that is observed in diplegic cases. These 
athetoid movements are usually intensified upon voluntary effort to use the 
limb. Attempts to grasp an object will often cause the fingers to move 
widely apart in extreme extension, and after clumsy, slow movements 
the object is awkwardly and insecurely held or the attempt fails. In 
some cases the extremities, particularly the upper one, are writhed about 
in the most vigorous, serpentine, and purposeless way, striking the 
patient's face or getting into awkward positions behind the neck or back. 

The athetosis in rare cases is persistent day and night, in others it 
subsides during sleep, and in still others, and perhaps the majority of 
cases, it only appears when provoked by voluntary effort or emotional 
disturbance. In the cases that are marked by excessive athetoid 
motility the muscles, from constant though involuntary use, are fre- 
quently firm and well nourished. They may even be over-developed. 



252 



DISEASES OF THE BRAIN PROPER. 



Clark 1 lias proven hypertrophy in such cases and actual enlargement 
of bones has been shown by the .r-ray. On the other hand, well- 
marked atrophy may be encountered. The joints frequently present a 






Fig. 90.— Attitude and deformity 
in cerebral right hemiplegia in a boy 
of seven. 



Fig. 91.— Right hemiplegia dating 
from birth, with overaction in right side 
of face and athetosis of right hand. 



marked increase in their range of motion so that the digits, for instance, 
can nearly be laid on the dorsal aspect of the hand. This condition is 
particularly marked in the severe cases, beginning very early in life. 
The ameboid and tentacle-like movement of the fingers and toes in 
athetosis, once recognized, can hardly be mistaken for anything else. 
Associated movements by which the paralytic member apes the positions 
and motions of the sound fellow reach their highest development in 
these cases in children. 

In the hemiplegic cases the arm usually recovers less than the leg 
or face and the athetoid condition is commonly confined to it. Con- 
tractures predominate in the foot and leg, producing an equinovarus, 
rarely a valgus, deformity, which is also favored by the shortness of the 
limb, and there is some tendency to contractured flexion at the knee and 
hip. The toes are frequently cramped and distorted by the contract- 
ures and hammer-toe is a usual deformity, but when athetosis is present 
an abnormal range of passive and active motion is found. In the face 
the tendency to contracture is frequently only shown in an overaction 
of the facial muscles during emotional expressions as shown in figure 
91, the boy being pleased at having his picture taken. Any degree of 

i " Jour. Nerv. and Merit. Dis.," Nov., 1902. 



THE CEREBRAL PALSIES OF CHILDREN. 



253 



mental enfeeblement may be present in hemiplegic cases, but usually it 
is much less marked than in the bilateral form and may be practically 



t 1 





Fig. 92. — diplegia dating 
from birtb. Rigidities ami spas- 
tic attitude witb cross-legged 
gait. 



Fig. 9o.— Piplegic congenital palsy with athetosis 
in face and all extremities. 



absent. The tendency to epileptic attacks and mental deterioration is 
pronounced in the hemiplegic form, and will be mentioned again. 

Dipleg-ic Cases. — In the bilateral form the unilateral conditions 
of the hemiplegic cases are present on both sides, but the lower limbs 
are, as a rule, more strongly aifected than the upper and the face may 
show little or no motor impairment. In rare cases the trouble seems 
to be limited to the lower limbs, and these instances are sometimes 
described as paraplegic. Almost invariably, however, the presence 
of speech difficulties, of mental defect, and of clumsiness in the use of 
the hands will betray the diplegia. The frequency of spinal hemor- 
rhages in stillborn children, as determined by Spencer, for instance, 
gives ground to suppose that in very exceptional instances the cord- 
lesion may alone occur and a true paraplegia result if the child 
survive. These bilateral cases are mainly of prenatal and birth origin, 
only a small number arising after the first few months of infancy and 
practically none after the third year of life. The more extensive 
injury to the brain is attended almost of necessity by greater mental 
impairment and idiocy marks many cases. Microcephalia some- 
times results or the skull may have so defective a shape that poren- 
cephalia and anencephalia may be suspected. Such children are 
either noticed to be rigid and inactive at birth, or after birth-in- 
juries and convulsive manifestation develop rigidity and contractures 
during the early months of infancy. Frequently it is only when 
the child is found incapable of learning to sit up or to use its legs in 



254 DISEASES OF THE BRAIN PROPER. 

efforts at walking that the paralytic state is recognized. Mental back- 
wardness, slowness in the development of speech, and other indications 
of injury to the highest brain functions are often neglected until the 
third or fourth year in the misguided hopefulness that the child will 
" outgrow it." The rigidity and spastic state is frequently so great that 
the legs and arms present a " lead pipe " resistance to passive move- 




Fig. 94.— Athetosis of feet. 

ments. Voluntary efforts are hindered or defeated, and some of these 
children never get the hands to the face, much less their toes to their 
mouths. They are difficult to handle and to dress. Their arms and 
legs are as unmanageable as stiff-jointed manikins. They are " all 
thumbs " and awkwardness. The spasticity in the lower extremities, 
which tends to flex hips and knees and especially to adduct the 
thighs, holds the knees closely together, makes it difficult to dress 
and bathe them as infants and defeats locomotion later on. Placed 
on a chair, the lower limbs have a tendency to maintain a rigid 
horizontal position. If they are placed on their feet the legs cross, 
the heels can not be brought to the floor, and if steps are taken it 
is only by advancing the foot that is in front and then bringing up the 
one in the rear. As they grow older a tendency to equinovalgus or 
varus and genu valgum is induced, but by keeping the feet widely 
separated they are able to dodge one knee around the other. They thus 
advance in a shuffling, knee-rubbing, toe-scraping, laborious manner, to 
which the increased reflexes and ankle-clonus give a jerky, tremulous, 
spastic character. 

In some cases more or less athetosis is present in all four members, 
and occasionally it invades the face and even the tongue, pharynx, and 
larynx. When the athetosis is general, and particularly when it in- 
volves the feet, the patients are rendered almost completely helpless 
physically. 

Little's Disease. — English, German, and American writers are 
prone to use the term Little's disease in a generic sense to embrace all 
cerebral palsies in childhood. French writers, of the Salpetriere school 
especially, insist upon a clinical form of spastic diplegia to which they 
give the distinctive name of Little's disease, after the London surgeon 
who among the first called specific attention to this class of disorders. 






THE CEREBRAL PALSIES OF CHILDREN. 255 

As these cases referred to present certain definite characters and a more 
hopeful future than the others, they merit separate mention. 

The initial condition is a premature birth or the birth at term of a 
markedly undeveloped child. This means a defective pyramidal tract 
in the spinal cord and brain. Such children usually weigh less than 
four pounds. Spasticity results in the territory of the lower neuron 
from the lack of control due to the undeveloped condition of the upper 
neuron. These children are rigid from birth, but the mental qualities 
are not necessarily diminished, and if they survive, the tendency is to 
continuous improvement as the pyramidal tracts develop. This develop- 
ment is never complete, but improvement continues up to the age of full 
growth. The motor condition is one of pure 
spasticity and there is no tendency to athetoid 
movements or epileptic attacks. The gait re- 
mains more or less spastic through life, which 
may be a long one marked by ordinary or even 
brilliant mental activity. 

Amaurotic Family Idiocy. — Sachs 1 pro- l /T 
poses this clinical designation for a group of |j 1/ / 

cases of which he collected nineteen occurring ^*f i \\J 

in ten families, with three autopsies. Numer- 
ous other observations have since appeared in 
current literature, notably those reported by 
Collier. 2 These children are born at term 
and present healthy physical and mental de- 
velopment up to the age of four to ten months, 
when they become weak, lethargic, and stupid. 
Ocular symptoms soon appear and blindness 
due to optic atrophy develops. Frey 3 does not 
agree with Sachs that the condition is merely 
agenetic, but considers the changes found to be 
postpartum, presenting for childhood the state Fig. 95.— case of Little's 

I 1 • i , 1 i disease. Rigidities and cross- 

recognized as amvotrophic lateral sclerosis in i eg from spasticity in a child 
adults. The ophthalmoscopic picture is said to be weighiug three pou " uds at birth - 
very characteristic. Beard 4 states that the appear- 
ance is not that of pronounced atrophy. The disc is not markedly blanched, 
but the fovea centralis presents a clear-cut liver-colored plaque surrounded 
by a halo of grayish-white which does not obscure the retinal vessels. Nys- 
tagmus, ocular deviations, and pupillary anomalies are frequently 
encountered. Autopsical findings have shown convolutional sim- 
plicity and cortical cellular degeneration. Sachs 5 reports degenerative 
changes in the gray matter of the entire cerebrospinal axis and even in the 
root ganglia. These changes have been attributed to toxic processes, but 
none of the alleged toxic factors can be accepted as competent in all in- 
stances. As many as four cases have been observed in a single family, 
and the inherent anatomical lack in the brain is not explained by inherited 
syphilis, which may, however, produce a very similar clinical picture. 

1 "New York Medical Journal," May 30, 1896. 2 " Brain," 1899. 

3 " Deut. Arch. f. klin. Med.," Bd. lxviii. 

4 " Jour. Nerv. and Ment. Dis.," May, 1900. 

5 " Jour. Nerv. and Ment. Dis.," Jan., 1903. 




256 DISEASES OF THE BRAIN PROPER. 

Epileptic Attacks. — One of the most serious features of the cere- 
bral palsies of children is the marked tendency to the development of 
epileptic attacks. These appear in fully one-half of all cases. They are 
due to the brain-lesion, and usually are most marked in the paralytic 
limbs, but with a tendency to spread and become generalized. True 
Jacksonian fits are but rarely encountered. In some cases the initial 
eclamptic attack is at once followed at regular intervals of weeks or 
months by these seizures. In others they do not appear for a period of 
years and may be preceded by petit mal attacks. They are always to be 
expected, and when established constitute a serious menace to the health 
and mental state of the patient. The ordinary tendency of epilepsy to 
induce dementia is exaggerated in these already defective brains. 

Diagnosis. — The diagnosis of cerebral palsy when the condition is 
well marked should present no difficulty. In the slighter grades the 
epileptic attacks or the choreoid movements are frequently mistaken and 
the organic basis overlooked. The combination of head symptoms and 
mental enfeeblement with the motor difficulties in diplegic cases should 
be sufficiently striking. The hemiplegic distribution of paralysis can 
tell but one story. In cases presenting paraplegic features it may 
require a careful investigation to locate the trouble in the brain. The 
history here, as elsewhere, is a valuable guide. In addition the pre- 
served electrical reactions, the comparatively normal trophic conditions, 
and the exaggerated reflexes should readily exclude a cord-lesion. The 
teratological defect which furnishes the cases of amaurotic family idiocy 
and the defective development of Little's disease must both be deci- 
phered from the clinical data or the post-mortem findings. 

Prognosis. — The prospects in these diverse cases vary widely, but 
it may be positively stated that complete recovery never occurs and that 
a perfectly normal condition is never attained. In the cases of prenatal 
origin the prognosis must rest on the observed course of development 
during the first year of life. Improvement in motor control and the 
appearance of mental awakening are hopeful indications, but the major- 
ity of these cases are doomed to mental retardation or idiocy and more 
or less physical helplessness. The cases that conform to the type of 
Little's disease are exceptions. In these the prognosis for mental de- 
velopment is good and progressive motor improvement, up to a certain 
point, may be confidently expected. Amaurotic family idiocy, which is 
a congenital defect, is, at present, of absolutely fatal prognosis. 

In the cases of birth palsy the intensity of the convulsions, their 
persistence, and the apparent extent of brain injury, in a very rough 
way, guide the prognosis as to life. If, after a few months, spasticity 
is still absent and some voluntary motion occurs in the paralyzed limbs, 
the prospects are much improved. The question of mental development 
can only be decided by watching the course of events. In the acquired 
cases the prognosis is much the same as in the apoplexies of adults as 
far as motility is concerned. The return of motion in the paralytic limb 
and the absence of contractures permit hope of a fair degree of motor 
restoration. Speech is usually restored, unless the frontal lobes have 
been injured and mentality impaired. The loss of sight and more 
especially of hearing is likely to prevent mental development and to in- 



THE CEREBRAL PALSIES OF CHILDREN. 257 

duce idiocy. Whenever epileptoid attacks appear, they constitute a very 
serious feature and foreshadow dementia, They are somewhat more 
common in the late than in the congenital cases and in the hemiplegic 
than in the diplegic palsies. 

Treatment. — In the birth-palsy cases the nutrition of the child is 
the first problem, as suckling and swallowing are often impossible. The 
evidence of meningeal hemorrhage is usually so indefinite that trephin- 
ing, which has been proposed, can rarely, if ever, be practised. The 
convulsions must be subdued by cold applications to the neck and head, 
and by sedatives, such as chloral, bromid, morphin, and by continued 
chloroformization, if necessary. The bowels should be thoroughly 
opened, preferably by means of calomel. The same measures are indi- 
cated as in older cases of acute hemiplegic convulsions and in convul- 
sions generally. 

In the later cases the management of the apoplectic and paralytic states 
is the same as for adults (see p. 222) . From the first, the nutrition 
of the paralytic muscles and the tendency to contractures must be met 
by massage, passive movements, and faradism. As soon as contractures 
appear, the massage and electricity must be used only on the weaker 
muscles — that is, as a rule, only on the extensors. The use of these 
measures to increase the strength of the overacting muscles may occa- 
sion decided harm. Unfavorable positions of the limbs must be obviated 
by mechanical measures, if necessary. Such means may do much to 
retard contracture, to hasten and increase voluntary control, and to 
favor growth in the paralytic members. Orthopedic appliances and 
tenotomies in neglected cases sometimes secure much permanent improve- 
ment. Transplantation of tendons has lately come into prominence, and 
in some instances can be resorted to with fair prospects of improvement. 

Athetosis may be subdued to a considerable extent by fixation 
appliances or plaster-of- Paris splints. Hammond reported some cases 
temporarily much benefited by nerve-stretching, and Horsley has extin- 
guished the athetosis by excising the corresponding brain-centers. In 
one such case the writer advised the removal of the cortical centers for 
a very unruly upper extremity, and the resulting palsy in the member 
was replaced finally by slight but useful voluntary control. Temporary 
flaccidity of spastic and athetotic members may be produced by intra- 
neural injections of absolute alcohol. During such periods the child can 
often gain material control of the muscles otherwise inhibited by the 
rigidities, and make substantial and lasting improvement, especially in 
walking. The intradural division of several posterior nerve-roots for 
the same purpose by Foerster's method has its advocates, and in severe 
cases is indicated. 

When idiocy is present, it is open to educational methods only. The 
epilepsy that so frequently complicates these cases can be controlled to 
some extent by bromids or combinations of various sedatives with 
bromids. When the attacks are of a distinctly Jacksonian character, 
the question of operation will come forward. Every case must be con- 
sidered by itself. As in many instances the condition is one of cerebral 
sclerosis, no operation can do good. If there be a cystic state, explora- 
tion and evacuation may be productive of much relief. In some cases 

17 



258 DISEASES OF THE BRAIX PROPER. 

the mere effect of the operation has been temporarily beneficial ; in others 
it has acted by relieving pressure. Removal of cortical centers in Jack- 
sonian fits of this class is very likely to merely displace the initial symp- 
toms and to add to the traumatic conditions already present. Linear 
craniotomy when the brain is diseased can only be condemned. If it 
have any place it is in the cases that present closed fontanels at birth 
with microcephalic heads, the possible result of early synostosis. Sharpe 
and Farrell 1 report much benefit in a few cases treated surgically by 
making a large decompression opening in the skull. In any case showing 
pressure symptoms such an operation or the simpler one of puncture of 
the corpus callosum by Anton's method 2 may be seriously considered. 



CHAPTER XI. 
TUMORS OF THE BRAIN, 

The encephalon is frequently invaded by various new growths 
common to other parts of the body, and by a number of neoplasms that 
are practically found only within the skull. In addition, new forma- 
tions arising from the meninges and cranial walls, while not strictly 
brain-tumors, present symptoms that are identical with lesions of the 
cortex, and are localized in the same way. The term " brain-tumor " is 
here taken broadly to cover new formations within the skull. 

Etiology. — The causation of brain-tumors is an obscure subject. 
Many of them arise by metastasis from distant morbid fields, as is 
usually, if not always, the case in tubercular growths, carcinomata, and 
parasitic cysts and masses. Some arise by intracranial extension from 
the orbit, pharynx, and cranial bones. Heredity, aside from tubercular 
aud syphilitic cases, plays a very insignificant if not an entirely negative 
role. Traumatism has probably been too frequently assigned as the 
inciting cause of brain-tumor, but it undoubtedly is competent in some 
instances. Thus, continuous symptoms have arisen within a few days 
of a head injury, and a tumor has subsequently been found at the trau- 
matic site or in the brain beneath. There can be no doubt that even 
slight head injuries may localize tubercular and syphilitic activity and 
lead to corresponding tumor growth. Sarcoma and glioma are the neo- 
plasms that seem to be most frequently attributed to trauma, but at the 
same time they are among the most common of brain-tumors. 

No age is exempt from tumor growth within the cranium. The 
great majority of cases occur in childhood and active adult life. The 
activity of tuberculosis in childhood, and the prevalence of syphilis in 
young adults, as well as liability to traumatic influences, may in part 
account for this. Males are somewhat more subject to cerebral tumor 
than females. 

Pathological Anatomy. — Of all brain-tumors tubercle furnishes 
the largest proportion. The implantation of the tubercular process 
within the brain sometimes gives rise to the formation of large, solitary, 
isolated, often encysted caseous masses that may be single, but are 

1 "Jour. Amer. Med. Assoc," Nov. 29, 1913. 

2 Anton and Braman, "Balkenstich," Berlin, 1913. 



TUMORS OF THE BRAIN. 



259 



multiple in about one-half of the cases. Tubercular tumors favor the 
base and the course of the large cerebral and cerebellar vessels, which 
recalls the usual propagation of tubercular meningitis. No part of the 
brain, however, is exempt. They do not destructively invade the 
brain-tissue, but displace it and act as foreign bodies, causing pressure 
atrophy. About them may often be found an area of tubercular infil- 
tration and inflammatory activity, especially if they are seated so as to 
involve the meninges. Three- fourths of the cases occur before the age 
of twenty. The tumors vary in size from a pea to a hen's egg, or even 
a larger size, and in number from one to a score. 

Sarcomatous growths are next in frequency. Usually they present 
the distinctive and important character of being more or less encapsu- 
lated and sharply separated from the brain-tissue, from which they can, 
therefore, if accessible, be easily enucleated. As a rule, they are out- 
growths of the cranial dura or periosteum, and the majority of them are 
situated in the basilar region, involving the brain-axis. In compara- 
tively rare instances they infiltrate the brain-tissue, or, arising at the 
vertex, spread out broadly. They are of rapid growth, and in a given 
case furnish pronounced, persistent, and uniform symptoms. They 
present the variations of cellular elements that mark sarcomata else- 
where. As a rule, they are single. 

Glioma is peculiar to nervous structures. It arises from the neu- 
roglia and finds its most usual seat in the brain, though it may occur in 





\ 



Fig. 96.— Sarcoma of right temporosphenoidal lobe. A, Basilar surface; B, transverse section 

(Dr. W. A. Jones). 

the spinal cord or retina. It presents a reddish, vascular color and a 
soft consistency quite like that of the brain-substance. Glioma is emi- 
nently an infiltrating and a destructive growth. Its outlines are difficult 
to determine. Owing to its strangulating effect, the center of a glioma is 
frequently filled with softened detritus and fatty-degeneration products, 
which may become fluid and the growth thereby cystic. Many alleged 
local " brain-hypertrophies " have been gliomatous infiltration in fact, 
and the microscopic examination of " cyst-walls " has alone discovered 



260 



DISEASES OF THE BRAIN PROPER. 



the true nature of the lesion in other instances. The favorite location 
of glioma is the white substance near the cortex, and it may infiltrate 
large areas, even the greater part of a hemisphere. Ordinarily it is single. 
In consistency they are soft, often highly vascular, and may in some 
cases be easily mistaken for angiomata. Hemorrhages not infrequently 
occur in them. In other cases a great amount of interstitial fluid gives 
them a myxoid character. 



,<\ i 




:Sr**. 



& 




Fig. 97.— Glioma of cerebellum containing recent and old hemor 




Fig. 98. — Gliomata of right temporosphenoidal lobe. 



Carcinomata, practically speaking, are found in the brain only as 
metastatic growths arising from primary cancer in the body organs, 



TUMORS OF THE BRAIN. 261 

breast, etc., or through direct invasion by extension from orbital or other 
cranial and facial carcinomatous growths. They are also practically 
confined to the second half of life. Uncontrolled by the soft tissue of 
the encephalon, carcinomata rapidly invade the brain, forming ill- 
defined, nodular, rarely encapsulated, very vascular, and practically in- 
operable tumors. When arising secondarily from cancer in the body 
organs, especially those in the thorax, carcinoma of the brain locates 
by preference in the neighborhood of the great vessels of the base. In 
other instances it springs from the choroid structures and the epithelial 
lining of the ventricles, or from the dura and pia mater. 

Cysts form tumors in the brain with comparative frequency. An 
encysted hemorrhage or softened infarct does not ordinarily give rise to 
progressive or marked irritative symptoms, and need not be here con- 
sidered. An encysted and latent abscess may, however, produce all the 
symptoms of a brain-tumor, which in fact it is. Cysts arising from 
parasites, such as the cysticercus and echinococcus, are rather common 
in some parts of the world, but are distinctly rare in the United States. 
Diamond 1 could only find eight reported cases of cerebral cysticercus in 
American literature. The central breaking down of sarcomata, and espe- 
cially of gliomata, produces cysts the nature of which may be indetermin- 
ate without histological search. Rarer forms are due to ependymal inclu- 
sions in embryonic development, producing later in life ventricular cysts 
or cysts in the posterior portion of the pituitary body. Dermoid 
cysts have also been encountered within and outside the dura, and 
especially in the cerebellum. Cyst development is usually slow, and 
the resulting tumor acts as a displacing foreign body. Their diagnosis 
is important, as they are readily evacuated and the cyst-wall may be 
removed when situated in a surgically approachable part of the brain. 
Syphilitic tumors of a gummatous sort in the brain are more fre- 
quent than statistics would indicate. Owing to their partial amenability 
to treatment and their readily accepted consequences they are seldom 
reported. As a rule, they spring from the meninges and large vessels, 
and, when deeply seated, are usually the ingrowth from one of the 
penetrating folds or vessels. They may be definitely limited or sur- 
rounded by softened brain-tissue, and have no tendency to infiltrate. 
Their usual location is in the hemispheres, especially at the base, or in 
the pons. They rarely occur in the cerebellum or central ganglia. 
After treatment their early soft, caseous, and gelatinous character 
may be changed to a shrunken, degenerated, and fibrous condition. 
They are usually multiple, nodular in form, and about the size of a 
chestnut. They occur as the result of acquired syphilis, and conse- 
quently usually in adults at periods varying from a few months to many 
years after the primary lesion. They are commonly attended by other 
syphilitic disturbances of the brain, such as endarteritis, meningitis, and 
cranial-nerve lesions. Of rapid growth, they usually promptly recede 
to some degree under adequate treatment, but their absolute removal 
by medication is always questionable. 

Many other tumor forms are occasionally found in the brain. 
Cerebroma is an embryological infolding of the gray mantle, which 
1 "Jour. Amer. Med. Assoc," June, 1899. 



262 DISEASES OF THE BRAIN PROPER. 

becomes occluded, usually in the white substance, and, later, takes on 
active proliferation, forming a heterotopic tumor. Fibroma, angioma, 
neuroma, psammoma, papilloma of the choroid plexus and Pacchionian 
bodies, actinomycosis, lipoma, teratoma, osteoma, cholesteatoma, etc., 
merely require mention. The pituitary tumor associated with acromegaly 
is discussed under that head, but tumors of various sorts, such as adenoma 
and adenosarcoma, occur at this point without such association. 

Aneurysms sometimes give rise to symptoms of intracranial tumor. 
They arise, especially after middle life, as the result of arterial disease, 
discussed in chapter v, or they may be due to traumatism. Aneurysms 
of a cirsoid character and of great extent that produce brain symp- 
toms are occasionally encountered on the meningeal arteries. The 
cerebral vessels present aneurysms usually of a globular or pyriform 
shape. Their favorite location is at the base and in the Sylvian fissures, 




a '• 



\ 




■ 



Fig. 99.— Aneurysm of the basilar artery. 



at the bend of the carotids, in the cavernous sinus region, and in the basilar 
artery, but they occasionally develop on the perforating arteries and may 
attain considerable size. The formation of miliary aneurysms and their 
relation to cerebral hemorrhage have already been indicated. Occa- 
sionally a patient with cerebral aneurysm is conscious of its pulsations 
and hears the bruit. The bruit may also sometimes be heard by auscul- 
tation of the cranium, but vascular murmurs have also been heard in a 
case of extensive softening and in vascular tumors. The chief symp- 
toms of aneurysm are due to pressure upon the cranial nerves and brain- 
centers. In only about one-third of all cases are clinical symptoms pre- 
sented that are fairly referable to the aneurysms. 1 

All brain-tumors cause more or less circumferential destruction 
of brain-tissue. This is at a minimum in slow-growing tubercles 
and reaches its maximum in rapidly growing and infiltrating glioma. 
Almost invariably, if the meninges are reached, an inflammatory 
thickening over the growth is added. In the case of tubercle and 
1 Beadles, "Brain," Oct., 1907. 



TUMORS OF THE BRAIN. 263 

syphilis a more or less diffuse meningitis is commonly present, sooner 
or later. The interpolation of a new growth within the resisting 
walls of the skull means increased intracranial pressure and dis- 
turbed vascular conditions. The effects are serious, relative to the 
intensity of the pressure, the rapidity with which it is established, and 
the location of the growth. Even a small tumor in the circumscribed 
space under the tentorium produces pressure rapidly. In the same 
way, if located near the falx or other resisting structure, its pressure 
effects seem to be greater. On the other hand, if' of slow growth and 
of a non-destructive >,naracter, a tumor may displace large portions of 
a hemisphere, especially in the latent regions of the right side, and 
attain enormous proportions, without producing notable symptoms. 
This pressure is felt not only in the vicinity of the tumor, but through- 
out the encephalon, and may cause symptoms and even inflammatory 
disturbance at a distance. Tumors so located as to obstruct the return 
circulation from the ventricles by occluding the straight sinus and the 
veins of Galen produce a dropsical condition of these cavities, an 
internal hydrocephalus, with extreme pressure indications. Even the 
bony walls of the cranium over the tumor are thinned and eroded in 
some instances, and that, too, when the tumor is not superficial. From 
local pressure conditions interfering with the circulation some edema 
of the brain in the neighborhood of the tumor is frequently found. 
In addition, the irritation produced by the tumor in some cases 
causes an actual proliferation of the glial fibers in the adjacent portions 
of the brain with decided macular hypertrophy of the convolutions 
or even of the entire hemisphere. This tendency, according to Spiller, 
may have much to do with herniation of the brain after decompressive 
and other operations. 

A number of observers have noted changes in the spinal cord in brain- 
tumor cases. These seem mainly to affect the posterior portions of the 
cord and the posterior roots. Ursini 1 considers them of toxic character, 
and Lubarsch has found somewhat similar changes in a case of gastric 
cancer. The analogous changes in anemias and cachexias are significant 
in this connection. Kirschgasser, 2 however, believes the cord changes 
to be secondary to increased tension in the dural sheath. Batten and 
Collier 3 take a similar view, and find such changes in over half of all 
cases. Certain cases in which the tumor disintegrates the motor tract 
within the skull show degenerative changes in the direct and crossed 
pyramidal tracts in the cord. 

Symptoms. — The symptomatology of brain-tumors presents the 
widest variations. The clinical picture is dependent upon the situa- 
tion of the growth and modified in its evolution by the nature of the 
tumor. A slow-growing mass starting from the meninges may deform 
an entire hemisphere without giving rise to symptoms, while another of 
insignificant volume may produce the most marked motor, sensory, and 
mental disturbances, or lead to sudden death. We may divide the symp- 
toms of brain-tumor into : (1) Those which are presented irrespective 

1 "Deutsch. Zeit. fur Nervenh.," 1897. 

2 "Deutsch. Zeit. fur Nervenh.," Bd. 13. 3 "Brain," 1899. 



264 DISEASES OF THE BRAIN PROPER. 

of the nature and location of the growth, — general symptoms; (2) those 
dependent upon the situation of the neoplasm, — -focal symptoms ; and 
(3) topical symptoms, those at the superficial site. Under certain condi- 
tions the general symptoms have some localizing value, as will be pointed 
out seriatim. 

General symptoms of intracranial growths are: (1) Headache; 
(2) generalized convulsions ; (3) mental impairment ; (4) double optic 
neuritis or optic atrophy ; (5) vomiting, and (6) vertigo. Tempera- 
ture changes above and below the normal, alterations in respiration and 
pulse rhythm, polyuria, glycosuria, insomnia, delirium, stupor, coma, 
slow speech, and malnutrition are common to brain-rumor and alt 
other encephalic lesions, especially in their terminal stages. In females 
amenorrhea is somewhat frequently encountered, especially in tumors 
located near the hypophysis, in the basilar area, and in the cerebellum. 

Headache. — In the great majority of cases of intracranial tumor 
headache is an early and persistent symptom. It has no necessary 
relation to the location of the tumor, and is usually frontal or occipital, 
less frequently parietal, or at the vertex. Sometimes the eyeball is the 
seat of pain. It usually increases with the increase in the tumor's size, 
and is aggravated by any effort or condition which increases arterial 
tension and cephalic hyperemia. In character the headache is dull, 
heavy, persistent, often with great exacerbations ; frequently it prevents 
sleep, and sometimes is of an intensity that becomes intolerable and 
submerges the patient's intellect. It has even been considered the cause 
of death. In rare instances a persistent, circumscribed headache has 
been found to conform to the tumor's location, and, therefore, like all 
diffuse symptoms, it may exceptionally have a localizing value. In 
such case there is often local tenderness on percussion, and sometimes 
local elevation of temperature. In cerebellar growths local pain and 
pain in the neck, with retraction of the head, are significantly common, 
but a cerebellar tumor may occasion continuous frontal pain. Pain 
in the distribution of the fifth cranial pair, or in a single branch, is an 
indication of local irritation of the nerve that may be confounded with 
the diffuse headache. 

General Convulsions. — Over one-half of all cases have general con- 
vulsions at some period of the disease. They may be the early and 
only manifestations of the tumor, and indistinguishable from ordinary 
epilepsy, for which these patients are not infrequently treated during 
long periods of time. More often the convulsions are preceded by 
headaches and focal symptoms. As a rule, Jacksonian fits eventuate 
in the generalized form, either by gradation or alternation. While 
these commonly conform to the clinical type of the ordinary epileptic 
seizure, a careful study of them sometimes enables one to detect varia- 
tions from the type that have some significance. The onset is less 
violent and abrupt. The clonic stage is likely to be protracted to 
fifteen minutes, a half hour, or longer ; there is less depth to the coma, 
and the subsequent deep sleep may be much abridged or entirely want- 
ing. They rarely appear with the regularity that is common in ordinary 
epilepsy. Attacks of the petit mal variety are rare in brain-tumor, but 



TUMORS OF THE BRAIX. 265 

do occur, while epilepsy presenting major attacks is rarely without 
minor manifestations. 

Mental Impairment. — The final stage of tumor cases is customarily 
marked by great hebetude and a stuporous condition that may increase 
into final coma. In lesser degree this belittling of mental vigor is 
common in the earlier periods of the disease, with or without convul- 
sions. Often a recurring tendency to stupor is encountered, a sort of sleep 
drunkenness. When the headache is intense, the patient is likely to seek 
seclusion, hold his head in his hands, and present a picture of dejected 
indifference that clearly indicates his mental state. He replies slowly to 
questions or disregards them utterly. He can not think quickly, and is 
sluggish in all his mental qualities as well as in his physical attributes. 
The pulse decreases in strength and rapidity, respiration is slow and 
shallow, and if suffering ceases the patient sinks into a sort of hibernat- 
ing sleep. From this apathy, which may be more or less marked, he 
partially rouses, or he may decline into a more comatose state and die 
of inanition. The two prominent characteristics of the mental state 
are apathy and suffering, which may be associated or alternate. So far 
as mental action can be elicited it is usually unclouded, except in rare 
periods of delirium. Something of this apathy may be noticed in com- 
paratively recent cases, and, as a rule, brain-tumor patients are little 
worried over their condition. In some cases the patient presents a silly. 
joking tendency out of keeping with his manifest ill health and alarming 
symptoms. Such mental changes are most likely to be well marked, and 
to appear early in tumors of the frontal lobes. Gianelli 1 reports 77 cases 
of tumor in the frontal lobes accompanied by mental disturbance and 20 
in which morbid psychic phenomena were lacking. In rare cases the 
mental symptoms closely imitate the formulated insanities, such as mania, 
melancholia, and even hallucinatory paranoia. 2 Knapp 3 with Dupre 
leans toward the conclusion that the mental symptoms are due to the two 
factors of pressure and toxic processes set up in the brain by the new 
growth through cellular disassimilation. 

Optic neuritis, or papillitis, occurs in about eighty per cent, of en- 
cephalic growths. In very rare instances only one nerve-head, usually 
on the same side as the tumor, has been found affected. In many cases 
the condition is more marked in one eye than in the other, and there is 
some reason to think that the more intense inflammation is also usually 
on the same side as the lesion. (For further details regarding this 
lesion of the second cranial nerve reference is made to Part II.) In 
chronic cases papillitis may suddenly appear, but a chronic papillitis or 
a very insidious one does not belong to an acute or rapidly developing 
lesion. The natural result of choked disc is atrophy of the optic nerve, 
which, therefore, has the same significance in the presence of other 
tumor indications. It must be borne in mind that central vision may 
not be greatly disturbed when the discs are distinctly choked, and their 
examination should never be neglected. This general symptom of 
brain-tumor is very constantly found in growths involving the cere- 

1 "II Policlinico," Julv 15, 1897. 2 Baverthal, " Munch, med. TYcchens," 1899. 

3 "Brain," 1906. p. 35. 



266 DISEASES OF THE BRAIN PROPER. 

bellum, p-eniculate bodies, corpora quadrigemina and the brain-axis. 
It, therefore, has a slight localizing value. Paton 1 has investigated the 
relation of the location of brain-tumors to optic neuritis in 200 cases, and 
concludes that primary atrophy is caused by direct or indirect pressure upon 
the optic nerve or chiasm ; that cortical tumors produce choked disc usually, 
and with a severity proportioned to the proximity of the growth to the 
chiasm ; that tumors affecting the thalamus, mid-brain, and cerebellum 
are practically always attended by choked disc ; that tumors in the white 
matter and in the pons do not cause choked disc until the cortex or 
the cerebellum respectively are invaded. Gushing and Bordley insist 
that interlacing and overlapping of the visual color-fields similar to 
those found in hysteria, are of such common occurrence as to almost 
justify their being ranked as one of the cardinal general symptoms 
of brain-tumor. Frequently this disturbance of the color-fields promptly 
subsides after decompressive operations. 

Vomiting. — Attacks of vomiting, usually of the so-called cerebral 
variety, without fermentation, nausea, and effort, are common. They 
may last for a few days or weeks ; subside and recur, and they usually 
attend other indications of tumor extension or invasion. Vomiting 
sometimes threatens death by inanition. Like choked disc, it is most 
frequent in tumors involving the cerebellum, especially the middle lobe 
and the corpora quadrigemina. 

Vertigo occurs with brain-tumors in all locations, but especially in 
the cerebellar and frontal regions. 2 It is a vague distress in some 
cases or a feeling of being submerged or of mere darkness and sinking, 
and may be paroxysmal or constant. In addition, brain-tumor may 
give rise to ocular vertigo by involvement of the motor oculi nerves, 
and to auditory vertigo by implicating the eighth nerve. In cerebellar 
tumors affecting its peduncles, especially the middle one, there may be 
forced movements and attitudes. In these combinations vertigo fur- 
nishes a valuable localizing indication. In some cases it is an epileptic 
equivalent. It sometimes is attended by vomiting. It may prevent 
the patient's rising from recumbency, or cause him to lie down if stand- 
ing. Ordinarily he grasps an object for support, and is soon over the 
attack. 

Focal Symptoms. — The symptoms due to the presence of a new 
growth or other lesion in special brain regions have been discussed at 
length in the opening chapters of this part. They consist usually of 
unilateral spasms confined to the face, to a limb, or to a segment of a 
limb ; of monoplegias ; of paresthesias of functional distribution; of hemi- 
anopsia or other sensory disturbances; of aphasia and apraxia ; of 
stereoagnosis and of impairment of the cranial nerves. They are vari- 
ously combined as associated anatomical structures happen to be in- 
volved. They advance with the tumor's growth, and change as irrita- 
tion yields to destruction. They thus vary indefinitely in different cases, 
and usually present numerous modifications in the clinical history of any 
given case. Williamson 3 gives particular importance to the significance 

1 "Brain," 1909, p. 65. 2 Bruns, "Wien. klin. Runds.," 1897, No. 46. 

3 "Practitioner," Sept., 1904. 



TUMORS OF THE BRAIN. 267 

of hemiplegia of very gradual onset which may at first be entirely unat- 
tended by the other usual symptoms of brain-tumor. To the Jacksonian 
fit, whether the spasmodic or the sensory features predominate, most at- 
tention has been directed, as it points with definiteness to the locus of 
greatest and usually of initial disturbance. To avoid needless repeti- 
tion, the reader is again referred to the previous chapters on cerebral 
localization and diseases of the cranial nerves. Hallucinations of the 
special senses occurring with convulsions or independently sometimes 
are caused by tumors situated in the corresponding sensory cortical area 
or influencing it more or less directly. 

Topical Symptoms. — The location of a new growth near the surface 
of the brain, so that it impinges upon the meninges or invades them, 
is sometimes attended by topical conditions of some significance. 
Local and persistent tenderness, heat, and headache may be thus induced. 
In the rare cases, where the cranial bones are perforated by erosion. 
palpation may detect the bony opening and the tumor mass. Invasions 
of the orbit, pharynx, and nasal cavities are open to ready investiga- 
tion. Percussion over large tumors superficially placed may demon- 
strate a changed pitch in the resulting note. 1 

Multiple tumors may furnish many diverse and conflicting symptoms, 
but usually one, owing either to its situation or major size, gives a pre- 
ponderance of manifestations. 

Course. — The majority of cases of brain-tumor are clinically of 
insidious onset, progressive development, and fatal termination in a 
cachectic state, induced by the gradually increasing intracranial pres- 
sure and the extinction of cerebral functions. The ordinary duration 
is from a few months to three years. The lethargy, stupor, and coma 
of late stages are frequently aggravated by paralytic features, and con- 
tinuous vomiting may defeat all attempts at nourishment. While this 
is true of the larger number of cases, there are numerous exceptions. 
Sometimes the first pronounced symptom is an apoplectic attack which may 
carry off the patient at once. The apoplexy is brought about by a cere- 
bral hemorrhage, due to erosion of a vessel, or sometimes to the tumor 
pressure obliterating an artery by thrombosis or by its mere mechanical 
effect. In the softer growths, notably gliomata, hemorrhage into the 
mass may take place and secondarily affect the cerebral structure. 
Hemorrhage into the substance of a tumor may also directly induce the 
apoplectic state and lead to a fatal termination. Gerhardt states that 
in this accident the initial fall of temperature that attends an ordinary 
cerebral hemorrhage does not occur. Some tumors give rise to no 
symptoms and are only detected after death from intercurrent disease. 

The nature of the growth in some degree determines the rapidity 
of the evolution of the case, but in turn is subject to its localization. 
Tubercle, fibroma, cerebroma, sarcoma, syphiloma, carcinoma, and 
glioma, in ascending order, increase in the rapidity with which they 
influence the brain-structure. The more rapid the growth, the more 
rapid the development of pressure and the more quickly does destruc- 
tion advance. Tubercles, however, furnish some of the most rapid as 
1 Bruns, "Wien. klin. Runds.," 1897, No. 46. 



268 DISEASES OF THE BRAIX PROPER. 

well as some of the most dilatory cases. A fatality is imminent in pro- 
portion as the growth recedes from the cortex and approaches the 
medulla in location. In the latter position or in its neighborhood, as 
in the basal ganglia, the pons and cerebellum, a small and comparatively 
benign growth may induce a rapid course and early fatal termination. 

The succession of symptoms is again determined by the nature and 
the location of the growth. Headache is, of all the diffuse or general 
symptoms, commonly the earliest, and optic neuritis usually follows in a 
few months. Spasms depend on the amount of irritation of the corti- 
cal structures, and paralysis on their destruction or the cutting of the 
motor paths. General convulsions, as pointed out, are often early feat- 
ures ; they especially precede the paresthesias and palsies. By the ex- 
tension of the growth invasion symptoms are set up (see p. 194), and 
a widening of motor and paralytic phenomena follows in anatomical 
order. Tubercular and carcinomatous growths, being usually secondary 
manifestations, bear with them the possibility of a rapid downward 
course from conditions outside the cranium. In addition, a tubercular 
neoplasm is likely to set up a diffuse tubercular meningeal infection that 
may promptly destroy the patient. A syphiloma in the same way may 
be attended by a wide-spread syphilitic meningitis. 

Diagnosis. — In a case presenting cerebral indications and giving 
rise to the suspicion of tumor, the diagnosis is much facilitated by a 
careful arrangement of the symptoms in the order of their develop- 
ment. A number of problems are presented: (1) Is there a tumor? 
(2) Where is it located ? (3) What is its size ? (4) What is its nature ? 
(5) Is it operable ? 

To the solution of the first question, is there a tumor, a definite 
answer can usually be given. Bruns says tumor may be diagnosed in 
eighty per cent, of all cases. After taking into consideration the evo- 
lution of the case, the focal or localizing symptoms are the most reliable 
data, but are strongly confirmed or rendered positive by the presence of 
the diffuse indications. Localized fits may be presented by ordinary 
epilepsy, but if headache, cerebral vomiting, vertigo, and choked disc, 
one or all, are added, the probability of tumor is enhanced. Should 
now the local spasm be followed by persistent paresis or paresthesia in 
the same locality, a positive statement is allowable. In the same way a 
hemianopsia or aphasia, following or associated with generalized or lim- 
ited convulsions and attended by some or all of the diffuse symptoms, 
permits a diagnosis of tumor. 

The clinical history of the case is important, as by it and its special 
symptoms Ave have to differentiate tumor from acute and chronic men- 
ingitis, with which, indeed, it may in some cases be complicated. The 
early and persistent headache is common to both, but tumor presents, as 
a rule, a choked disc, while meningitis has a neuroretinitis. Meningitis, 
even of the tubercular form, is of comparatively rapid development, 
while tumor commonly requires months. In meningitis the motor 
symptoms are usually bilateral, as contrasted with the one-sidedness of 
tumor disturbance. It will be recalled that a latent cerebral abscess 
may present all the indications of a tumor, which indeed it is, and it 



TUMORS OF THE BRAIN. 269 

requires no differentiation aside from the fact that it offers a better 
operative outlook. The cerebral palsies of childhood and general paresis 
in adults have been confounded with tumor, but a careful scrutiny of 
the case, with a knowledge and mindfulness of these maladies, will 
obviate error. The tumors which present a sudden apoplectic onset 
may be confounded with cerebral hemorrhage or softening. Here the 
ordinary antecedents of vascular disease and the arterial condition pre- 
sented furnish a strong presumption of vascular accident, and serve 
to a reasonable degree to exclude tumor, if the diffuse symptoms of 
tumor are lacking. It will, however, be borne in mind that a brain- 
tumor may bring about vascular disease, and that hemorrhage into 
gliomatous and other soft growths may produce apoplectic states which 
would be further favored by atheromatous conditions of the blood- 
A T essels. The diagnosis must rest on the antecedent and sometimes on 
the subsequent history of the case. 

There is reason to hope that skiagraphy may give aid in the diagnosis 
of brain tumors. Obici and Ballici l were able to thus demonstrate a 
sarcoma in a cadaver. The writer, 2 Mills, 3 and many others have ob- 
tained similar results during life. Great vascularity, hemorrhage into 
the tumor, or calcareous changes in or about the mass favor the x-ray 
detection of the growth. 

In Europe Xonne, Oppenheim, Grasset, in this country Hoppe and 
others have called attention to numerous cases of pseud ocerebral tumor 
presenting many of the most important symptoms of tumor, but either 
ending in recovery or showing no pathological changes at operation or 
necropsy. Finkelnburg and Eschbaum 4 also report a number of such 
cases, but find a chronic leptomeningitis or hydrocephalus with neuritis 
to be present. 

The second question, of location, is answered, if answerable at all, 
by a consideration of the focal and topical symptoms of the case and 
the localizing bearing of the diffuse symptoms that are presented. The 
absence of focal symptoms points to the regions of latent lesions in the 
frontal, temporosphenoidal, and postparietal regions, especially on the 
right side. 

It is necessary to answer the second question before the third can be 
approached, as we can only relatively estimate the size of a tumor by 
knowing its location and the anatomical regions invaded. To this end 
the sequence of developments is our greatest aid. Invasion symptoms 
enable us to trace, especially in the motor cortex, the gradual growth 
of a tumor, and in some directions to indicate its extent. If 
this can be done on a portion of the periphery, a knowledge of the 
symptoms that would arise by the tumor's extension in the opposite 
direction may enable us to say whether or not such centers or pathways 
have been seriously invaded. It is evident that only a very inexact 
measurement can be made, and this is especially true if the growth is 
situated in the neighborhood of the latent lesion territories. 

To the fourth question, what is the nature of the tumor, a posi- 

1 "Rivista di Pathologica," Oct., 1897. 2 "Amer. Jour. Med. Sciences," Feb., 189C 
3 "Phila. Med. Jour.," Feb. 23, 1902. i "Deutsch. Zeit. fur Nervenh.," 1909. 



270 DISEASES OF THE BRAIN PROPER. 

tive answer can never be given, unless there is an external portion of 
the tumor, but a strong probability is frequently forthcoming. In this 
relation the age, the diathesis, the history of previous illness, the pres- 
ence of various diseases, the location of the tumor, its rate of develop- 
ment, and the effect of treatment aid us. In childhood, tubercle, glioma, 
sarcoma are most frequent ; in adults, the firmer tumors and syphiloma ; 
in advanced years, carcinomata. The presence elsewhere of tuberculosis, 
carcinoma, parasitic cysts, or syphilis gives much weight to the supposition 
that the brain-lesion is of a similar character. Tubercle and glioma 
favor the pons and cerebellum. Syphilis favors the pons, basilar area, 
and cortex, but is rare in the cerebellar white matter and the centrum 
ovale. Fibroma and glioma, being interstitial growths, occur in the 
deep structures. Sarcoma mostly occurs in the ventricles or meninges. 

A rapid onset, followed by a stationary period, speaks for tubercle, 
especially in the first half of life. Glioma and sarcoma are of insidious 
and steady development. Apoplectic seizures in tumor cases usually 
mean glioma. Syphilis provokes a rapid onset and course. 

Only syphilitic tumors are permanently affected for good by treat- 
ment, but it must be said with due emphasis that the iodids are capable 
of apparently checking sarcomatous growths and frequently cause tempo- 
rary and misleading benefit in all forms of tumor, probably by favoring 
the removal of the circumscribing edema. 

The fifth question concerns the possibility of surgical removal. 
From the large statistics compiled by Starr, and from later additional 
data, it can be stated that not more than seven times in a hundred cases 
of brain-tumor is the growth enucleable. Unless the neoplasm lies on or 
in the convexity of the cerebral hemispheres it is not readily approach- 
able. Piollet 1 tabulates forty-eight cases of cerebellar tumor surgically 
removed. In twenty death promptly ensued ; in sixteen improvement 
with subsequent death from recurrence of the growth ; in four almost 
complete cure, and apparently complete cure in one only. Frazier, 2 
from a study of 116 operations of recent date, draws the following data: 
Recovery, 15 percent.; improved, 28 percent; unimproved, 15 percent; 
mortality, 42 per cent. Cerebellar cysts offer a good operative prospect 
The basilar, pontine, and medullary regions are out of the operative 
field excepting growths in the cerebellopontine angles, which usually 
are of extra-cerebral origin, and are comparatively favorable for ser- 
gical attack. Cysts and old abscesses are readily drained. Sarcomata 
can usually be enucleated, tubercles and fibroid tumors can be shelled 
out, but glioma, from its infiltrating character, and other similar growths 
can never be entirely removed, and grow again if the attempt is made. 

Prognosis. — If ninety-three per cent, of brain-tumors are inoper- 
able, and syphiloma is only partially amenable to medicinal treatment, 
the gravity of the disease is apparent. The great majority of cases 
run their course within three years, though slow-growing neoplasms 
may exist almost an indefinite time or may only furnish a post-mortem 
surprise. The outlook turns upon the nature of the growth and the 
associated clinical manifestations. The possibility of sudden death 
1 "Arch. Provinc. de Chirurg.," 1901. 2 "N. Y. Med. Jour.," Feb. 18, 1905. 



TUMORS OF THE BRAIN. 271 

should not be overlooked, especially in tumors located in or near the 
brain-axis. 

Treatment. — The management of brain-tumors is of two sorts : 
(1) That directed to the tumor itself, and (2) that to the general physical 
condition. Removal of the tumor by operation is possible in a small 
number of cases, and should be done whenever indicated and the condi- 
tions are otherwise favorable. This surgical proceeding in the hands of 
competent men has secured some brilliant results and saved and pro- 
longed life. Oppenheim states that good results have been obtained in 
about one-half of all well-selected cases. Even in inoperable tumors 
a wide opening of the skull has relieved pressure, has benefited the 
mental condition, stopped the headache, and caused the choked disc to 
subside. It is indicated in at least five-sixths of all cases, according to 
Knapp. 1 Indeed, in some cases it has seemed to cause the tumor to 
recede. The simple operation of Anton, puncture of the corpus cal- 
losum, seems to produce a permanent drainage of the ventricles, and 
in tumors of the base has proved a valuable procedure. As above 
indicated, cerebellar tumors are not the most favorable for operation. 
The harder and slower growing sorts of brain neoplasms offer the best 
operative results. Tubercle, sarcoma and fibroma, or their varieties, 
can be removed en masse, while the limits of infiltrating growths are 
difficult to distinguish and complete removal is practically impossible. 
Cysts and abscesses can be evacuated, and if the secreting wall is re- 
moved, a practical cure follows. Should the cyst be due to degenera- 
tion of a sarcomatous growth, the probability of a return is very great. 
In syphilitic growths intensive treatment with mercury, arsenic, and 
the iodids usually produces prompt improvement. This goes so far 
that many cases are alleged to be cured, and the shriveled remains of a 
syphiloma have been found post-mortem to testify to the efficacy of 
treatment and the precision of diagnosis. A large degree of reservation, 
however, should be maintained in every syphilitic case. As a rule, the 
cure is not complete. Some residuum of disability can usually be de- 
tected, and a constant tendency for the syphilitic process to reappear 
during the rest of life too frequently keeps these patients fighting the 
disease as long as they live. In order to secure the best results mer- 
cury, arsenic, and iodid should be used, either together or in succession, 
depending upon the urgency of the condition, and, carefully guarded, 
should be pushed to the limit of toleration. Explicit directions for the 
treatment of syphilis will be found in the chapter on Syphilitic Diseases 
of the Nervous System, Part VI. 

As tumors of all varieties have shown at least temporary improve- 
ment under the use of antisyphilitics, the practitioner must be guarded 
in drawing inferences from such therapeutics, and not allow himself to 
take too favorable a view of the case when this occurs. It is an estab- 
lished rule to use specific treatment in all cases of brain-tumor where 
there is a shadow of a doubt as to their character. If, after three weeks 
of vigorous treatment, no benefit is obtained, the lesion is pretty surely 
not syphilitic. Should improvement take place, a continuance of treat- 
3 "Boston Med. and Surg. Jour.," Oct., 1899. 



272 DISEASES OF THE BRAIN PROPER. 

ment should be persisted in until all symptoms have practically disap- 
peared. A return of former symptoms or further development of tumor 
indications in the face of specific treatment practically demonstrates the 
non-syphilitic character of the disease. Specific treatment must never 
be depended upon if blindness is threatened. A decompressive opera- 
tion should always be urged if the choked disc be intense, or if a notable 
and progressive narrowing of the visual field or sclerotic changes about 
the vessels of the disc indicate a beginning atrophy. Horsley contends 
with much reason that when attackable, even syphilomata should be 
treated surgically after a fair trial of specific medication, and Coombs 
Knapp 1 found nine out of ten such operations to have been successful. 
The patient's general condition will require constant attention. 
Tuberculous and other cachectic states have their own requirements. 
The headache can often be relieved for a time by brisk cathartics and 
hot baths. Antipyrin and other coal-tar analgesics often control the 
headache for a time. The opiates are frequently powerless except in 
extreme doses, and their use should be postponed to the last possible 
moment. Vomiting yields best to nerve sedatives, such as the bromids, 
and to measures like hot baths and mustard foot-baths, calculated to 
decongest the cerebral circulation. In rare cases it is quite unmanage- 
ble, even by morphin, and may lead to rapid inanition and death from 
exhaustion. Convulsions can usually be restrained by the bromids. The 
continued use of bromids and antipyrin will be found especially valu- 
able in these cases, and a flagging heart may be protected by caffein or 
strychnin. The optic neuritis can be benefited in syphilitic cases by 
medicinal treatment. In other sorts of growth it is frequently benefited 
by operation. Repeated spinal puncture may also yield palliative results. 
It must be used with caution, as in cases of great pressure, and particularly 
when the growth is in the posterior fossae, the reduction of intraspinal 
tension may lead to the downward forcing of the brain at the foramen 
magnum, causing medullary pressure and serious symptoms or even death. 
When optic atrophy has once occurred, it is permanent. Finally, by 
nutritious diet, baths, massage, and general measures the strength of the 
patient is supported and life prolonged. 

1 "Boston Med. and Surg. Jour.," Oct., 1899. 



HYDROCEPHALUS. 273 



CHAPTER XII. 

HYDROCEPHALUS* 

Hydrocephalus is a term loosely used to designate any undue 
amount of watery fluid within the skull, and in such a sense is 
synonymous with dropsy of the brain. Tubercular meningitis, fre- 
quently called acute hydrocephalus by older writers, is not the condi- 
tion in question. Nor are we now to consider the compensatory increase 
of cerebrospinal fluid occurring in the coirvolutional shrinkage of old age, 
or in the cerebral atrophy of dementia, or in porencephalic or anencephalic 
defects. The question does not pertain to the increase of fluid which 
marks acute, serous or tubercular meningitis, or to the edematous 
state that frequently attends cerebral tumors. Attention has also been 
called in the proper place to yentricular distention resulting from 
tumors situated in the posterior cranial fossa?, which mechanically block 
the yenous return through the veins of Galen and the straight sinus. 
It is desired to restrict the term hydrocephalus to a congenital or acquired, 
acute or chronic condition marked by great increase in the amount of 
cerebrospinal fluid within the skull attended by compression of the 
brain. In some cases it is entirely yentricular, constituting internal 
hydrocephalus; in others it is subdural, constituting external hydro- 
cephalus. 

Etiology. — The causation of hydrocephalus is obscure. Some 
families seem to be marked by a hereditary tendency to it, as shown by 
several cases occurring in the same or succeeding generations. Heredi- 
tary syphilis has for long been thought to be a competent cause, but 
in many cases it can be excluded with a reasonable certainty. Its 
causal relation is supported by Heller 1 and by Titomanlio 2 in careful 
studies. Alcoholism on the part of the parents is also supposed to have 
some part in producing the congenital variety, and is doubtless active in 
some of the late adult cases. Traumatism after birth has produced it, 
and it has been noted as a sequel of cerebrospinal meningitis 3 and of 
Quincke's acute serous meningitis, the symptoms of which do not vary 
materially from those of the ordinary infectious variety, but it is marked 
by the rapid production of subdural hydrocephalus and great intra- 
cranial pressure. 

A pituitary tumor, a tumor in the neighborhood of the pituitary gland, 
or in the pontocerebellar region is sometimes found. 

Morbid Anatomy. — In congenital cases and in those occurring be- 

1 "Deut. med. Wochens.," June 30, 1892. 

2 Trans. Section on Diseases of Children, International Med. Cong., Rome, 1894. 

3 E. P. Joslin, " Aim Jour. Med. Sci.," Oct., 1900, eight cases. 

18 



274 DISEASES OF THE BRAIN PROPER. 

lore the cranial bones are firmly united the head is enlarged, sometimes 
to vast proportions. The cranial bones are usually reduced in thickness, 
often to that of paper, the diploe being absent. At the same time they 
are frequently much broadened. The sutures are patent, or super- 
numerary bones are commonly found if synostosis has taken place after 
the disease has been present for some time. The frontal, occipital, and 
squamous portions of the temporal bones are displaced outward. The 
parietals conform to the globular shape of the head. 

The amount of fluid may be incredibly increased, and as much as 
three gallons has been noted in a very extreme case of long standing. 
It is a colorless fluid of low specific gravity, quite similar to chronic 
effusions in other fibroserous cavities, and closely resembles normal cere- 
brospinal fluid. 

' The principal distention is usually in the lateral ventricles, which 
bulge in all directions and stretch out their cerebral walls into a thin 
lining for the enlarged cranial cavity. The basal ganglia are often 
compressed and flattened. The ventricular lining is found usually, if 
not always, in a thickened, granular, hypertrophic condition. It may 
reach a thickness of half an inch. The choroid plexuses are corre- 
spondingly enlarged. This apparent ependymitis often serves to occlude 
the ventricular aqueducts, so that the third and fourth ventricles may 
not share in the dilatation or it may be confined to one lateral cavity. 
In about one-half of the cases connection with the spinal spaces is 
obliterated. In the congenital and adult cases it is common for all the 
cerebral ventricles and the cord to be involved. When the third and 
fourth ventricles are affected, the optic tracts suffer and optic atrophy is 
common. At the same time the cerebellum, pons, and medulla are 
defectively developed. The meninges may show little or no change. 
After cranial solidification the anatomical conditions are modified by the 
resistant character of the skull. The amount of fluid is necessarily less, 
but the pressure falls more directly upon the cerebrum. 

Symptoms. — Hydrocephalic enlargement of the head sometimes ren- 
ders birth difficult or requires the use of the perforator before extraction 
can be accomplished. In other and a majority of the cases the condition 
is insignificant or unnoticed at birth, and appears during the first year of 
life, especially during the first six months. The head gradually or rap- 
idly enlarges in all its diameters and measurements. An increase in 
the circumference of the head at a rate of a centimeter daily has been 
noted, but usually it requires several weeks for that amount of enlarge- 
ment to take place. The outline of the skull is globular and may 
overhang the face, ears, and occiput, which are not correspondingly en- 
larged. The internal pressure is manifest at the bulging fontanels, 
which are increased in size and connected by wide-open sutures. The 
return circulation of the cerebrum is impeded, and the collateral veins in 
the scalp and face become distended and strikingly apparent. From the 
outward tilting of the frontal bones the orbits are directed downward and 
the ocular globes are often maintained in the same direction, even to such 
a degree that the cornea is only seen with difficulty. Optic atrophy and 




HYDROCEPHALUS. 275 

blindness are frequent. Nystagmus and strabismus are common. Fluc- 
tuation is readily obtained on palpation, and the head, in extreme cases, 
may be translucent. 

The hydrocephalic child shows little ac- 
tivity, can not raise its head sometimes, or only 
does so with the aid of its hands. There is a 
tendency to peevishness and restlessness or 
somnolence and coma, broken by generalized 
convulsions and a frequently repeated distressed 
cry. Older children complain of pain in the 
head. The body and limbs suffer in their nu- 
trition and are unequal to the task of holding 
up the head and trunk. In some cases spasti- 
city develops in the limbs, especially in the 
lower ones, and some paralytic loss of power is 
frequently noted. Vomiting is frequent and 
mav be provoked by movements or much .*> ipo.-chronic hydro- 

/ ( i J cephalus m a child of four 

handling". years. Circumference of head, 

27 inches 

If not rapidly fatal by exhaustion, convul- 
sion, coma, or syncope, the disease may come 

to a standstill or proceed with such slowness that the child is enabled, 
in some defective measure, to maintain growth and develop its physical 
and mental faculties. These are both invariably much retarded, so that 
the body is dwarfish and in great disproportion to the cephalic enlarge- 
ment. The occasional cases that live to mature years are more or less 
imbecile, clumsy, and physically defective, though a slight degree of 
hydrocephalus is not incompatible with mental brilliancy. Many cases 
of marked dolichocephalia in adults with beetling brow and salient oc- 
ciput prove the possibility of recovery. 

When hydrocephalus is acquired subsequent to cranial synostosis, the 
symptoms are vague, and only rarely can the condition be deciphered 
ante mortem. The indications are not unlike those of tumor. It 
usually follows head injury. Mental impairment, especially of memory, 
vertigo, vomiting, insomnia, headache, convulsions, and rigidities are 
encountered. Hemiplegia is rather frequent. The pupils are dilated 
and stationary. Strabismus is common. Periods of coma are frequent 
Death may be sudden or follow coma. 

Course. — The disease presents a varied course. The congenital 
cases may run rapidly to a fatal termination in a few weeks, while others 
come to a standstill and allow a fair degree of adult development and 
a comparatively long life. As a rule, marked hydrocephalic cases do 
not reach maturity, but give out at adolescence and puberty, if not 
sooner carried off by convulsions or comatose conditions referable to the 
intracranial pressure. It is extremely rare for them to live beyond 
thirty. In the acquired adult cases a fatal termination is usual within 
two or three years, and often sooner. 

Diagnosis. — The diagnosis in infantile cases can hardly offer any 
difficulty if the tendency to cephalic enlargement is noted. The globular 
shape of the head should distinguish it from the rectangular conforma- 



276 DISEASES OF THE BRAIN PROPER. 

tion of rickets with the enlarged and squared forehead and prominent 
frontal eminences, though patency of fontanels is usually present 
in both. The appearance of rickety conditions in the long bones and 
at the costal extremities is also significant. The two conditions, how- 
ever, may be associated. Before the head shows much or any abnormal 
increase it is difficult to exclude meningitis, which may, indeed, be the 
causal condition. The treatment, however, is very similar in both. 

In adults the diagnosis is well-nigh impossible, and when suspected 
can only be confirmed by an autopsy. A condition acquired after com- 
plete union of the cranial bones, commencing anywhere from five to fifty 
years of age, — hyperostosis cranii, — may at first sight mislead. The his- 
tory will at once differentiate it. Rotable hydrocephalic enlargement 
must begin in very early life. In hyperostosis cranii the size of the 
head is due to a thickening of the cranial bones, and the bones of the 
face and spine are usually affected in a similar way. The enlarged 
head of acromegalia may be distinguished by its late development and 
the associated deformities of face, hands, and feet. 

Prognosis. — The prognosis for life is always grave. The great 
majority of cases die within a year. A few with enormous heads live 
for a few years, and in those marked by a stationary condition life is still 
usually much shortened. The outlook for mentality is also darkened, 
but must be estimated for the individual case. Mental enfeeblement 
is the rule, and this may be mere childishness or pronounced imbecility. 
Epileptoid attacks are of serious import both as to life and mental 
development. 

Treatment. — The treatment of these cases is medical and surgical. 
Mercurial inunctions to the head and the use of iodine preparations have 
long been practised. It is probable that some of the good results 
attributed to these measures are not due to their alleged stimulation of 
absorption, but to their influence on a syphilitic factor. As a rule, 
they are of little value, and should only be used when there is suspicion 
of specific taint. Catharsis and other violent elimination is to be 
discountenanced, as it only serves to exhaust the patient's diminished 
strength. When the process is active, the application of cold to the neck 
and head by ice-bags or flexible coils is valuable. A slight mercurial 
action, preferably by calomel in minute and frequent doses, should be 
used. Convulsions require sedatives, especially bromids. 

Strapping the head with surgeons' plaster or the application of elastic 
caps and bandages have been advocated, but are usually intolerably pain- 
ful and aggravate the pressure conditions. Repeated tappings through 
the fontanels or by lumbar puncture have been employed with varying 
results. Occasionally they have seemed to be successful, but lumbar 
puncture will be fruitless in at least half of the cases owing to the lack 
of communication between the brain and cord spaces. * Only a moderate 
quantity of fluid should be withdrawn at a time, and the strictest anti- 
septic precautions must be employed. Some have ventured to withdraw 
fluid and inject iodine solutions as in the treatment of hydrocele, but the 
plan can not be advocated. Too frequently the punctures result in a 
1 d' Astros, "Les Hydrocephales," Paris, 1898. 



HYDROCEPHALUS. 277 

meningitis that carries off the patient. Plans of constant external 
drainage have been devised, and, while attended in some cases with 
temporary benefit, the result has been uniformly fatal. 

A case has been reported by Rokitansky in which spontaneous rup- 
ture under the scalp led to a recovery. The idea occurred to Dr. L. L. 
McArthur, of Chicago, to drain the ventricular cavities into the areolar 
spaces beneath the scalp by the insertion of drainage-tubes or silk into 
the cranial cavity through a drill-opening above and back of the ear. 
He attached the drainage material to the pericranium, and then, secur- 
ing first-intention healing in his overlying scalp-flap, allowed the serous 
accumulation to flow. A hygroma tous swelling forms under the scalp, 
from which absorption seems to be rapid, and the head diminishes in 
size if the bony sutures are not united. This operation was done for 
the writer on the case shown on page 275, with immediate and lasting 
improvement. In two other cases it also demonstrated its utility. 
Mikulicz and Troje 1 have had favorable results with the same method 
independently devised. The insertion of a drainage-tube into the 
ventricle and terminating in a broad flange under the dura to which it 
is secured, thereby connecting ventricular and meningeal areas, is prob- 
ably the best plan, unless the simple method of puncture of the corpus 
callosum, devised by Anton ("Balkenstich") proves better. Others have 
established drainage from the lumbar spinal spaces into the peritoneum. 
Even the third ventricle has been opened by the surgeon and the choroid 
structures clipped off with distinct advantage in the cases that survived, 
probably due to the establishment of permanent drainage. The dis- 
advantage of all surgical procedures is the liability of infection and 
meningitis, and the peculiar tendency of these cases to sudden death 
from removal of fluid or from the inhibition of the heat-controlling 
mechanism, which allows the temperature to exhaust the patient in a 
few hours. 

1 "Centralblatt f. Chir.," Sept. 5, 1896. 



PAET IV. 

DISEASES OF THE SPINAL MENINGES AND 
SPINAL NERVES. 



CHAPTER I. 



SPINAL MENINGITIS AND SPINAL MENINGEAL 
HEMORRHAGE. 

Spixal meningitis is an inflammation of the covering membranes of 
the spinal cord. The varieties of meningitis ordinarily described have 
been somewhat arbitrarily based upon their anatomical location. The 
terms pachymeningitis and leptomeningitis are respectively employed, as 
the dura or the softer membranes are principally involved, but a sharp 
division is clinically impossible, and is not found post mortem. For 
purposes of description we may consider : (1) Pachymeningitis, or ex- 
ternal and internal inflammation of the dura ; and (2) leptomeningitis, 
or inflammation of the pia. Inflammation of the inner surface of the 
dura, from contiguity, must involve the leptomeninges more or less, so 
that the conditions are usually associated, and meningitis, originally 
external, may finally invade the pia. Owing to the very intimate rela- 
tion of the pia and the fibrous septa of the cord, association with mye- 
litis is frequent. A mixed form, meningomyelitis, is common. 

Pachymeningitis Externa Spinalis. — Pachymeningitis externa, 
or ^external clural meningitis of the spine is due to chronic irritation and 
inflammatory conditions invading the spinal canal, and is, therefore, 
secondary to other morbid states. Vertebral tuberculosis, Pott's disease, 
abscesses and new growths near the spine, inflammation and purulent col- 
lections in the pleurae, mediastinum, peritoneum, and pelvis, and sacral 
bedsores may be the source of the meningeal thickening. This gives rise 
to symptoms mainly by irritation of the sensory and motor nerve-roots 
passing through the area of disease. When the thickening becomes ex- 
treme, as occasionally happens, it may be sufficient to compress the cord 
and give rise to pressure symptoms and a spastic paraplegia similar to 
that of a cross-myelitis. The condition is usually due more to the 
inflammatory invasion of the cord than merely to pressure. There is 
local tenderness over the spine, shooting or constant pains in the dis- 
tribution of the irritated nerves, twitching of their muscles, and hyper- 
esthesia in their cutaneous areas, which may go on to anesthesia and 

278 



DISEASES OF THE SPINAL MENINGES. 279 

muscular palsy if the nerves be sufficiently compressed or inflamed to 
cause their degeneration. 

Anatomically, the dura is found hyperplastically thickened, with 
much adventitious fibrous tissue, and is frequently covered by a caseous 
or purulent deposit or involved in a new growth. The various find- 
ings, of course, depend upon the nature of the primary disease. When 
the thickening is extreme, the soft membranes are adherent to the dural 
tumescence and may be indistinguishable. The cord then shows a con- 
striction, and may, in severe cases of long standing, be very consider- 
ably reduced in size at the place of disease presenting local myelitis and 
secondary ascending and descending degenerations. 

The diagnosis is usually not difficult if the primary disease is 
recognized. It may be confounded with myelitis, with which it is often 
associated late in the case. The clinical history shows a preponderance 
of pain, spasm, and irritation, a chronic course, and an early absence of 
paralysis ; while in myelitis the rapid onset, the relative absence of pain, 
aside from the girdling sensation, and the promptly developed paralytic 
state with early bladder and bowel symptoms are distinctive. 

Owing to the serious nature of the causal conditions, the prognosis 
is bad and treatment is practically surgical. The pachymeningitis externa 
associated with Pott's disease is perhaps the least grave, as the proper 
orthopedic and surgical management of such cases frequently is followed 
by practical recovery even when the cord has probably been notably 
compressed. 

Pachymeningitis Interna Spinalis. — Pachymeningitis interna, or 
internal inflammation of the spinal dura, is described as (1) hypertro- 
phic and (2) hemorrhagic. In reality, these forms are but stages of one 
and the same process, the thickening and hypertrophy following upon 
the organization of the hemorrhagic exudate. The term " hematoma of 
the spinal dura mater" has been sometimes used. The condition is a 
rare one, and usually the cerebral meninges are also similarly affected. 
It is most commonly found in general paralysis of the insane and 
chronic alcoholism. 

The portion of affected dura presents on its inner surface a very 
considerable thickening, which may be a layer of reddish-brown exudate 
or consist of laminations of fibrous tissue, the apparent result of the 
organization of successive hemorrhagic exudations. It may attain 
sufficient size to constrict the cord. The softer, more recent, and 
reddish or brownish layers consist of fibrin and blood. The distribution 
is frequently extensive, but in some instances it is confined to a com- 
paratively short vertical extent of the envelope of the spinal cord, and 
is then more frequently situated in the cervical region. This circum- 
scribed cervical form was first described by Charcot and Joffroy, who 
give it the name of pachymeningitis cervicalis hypertrophica . 

Syphilis, trauma, alcoholism, and exposure are regarded as competent 
causes, and hence it occurs, as a rule, in adult males, though some 
cases in children are recorded. 

The condition is essentially chronic and of slow onset. At first 
irritation of nerve-roots gives rise to local pain and hyperesthesia over 
the spine and in the peripheral distribution of the spinal nerves of 



280 



DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 



corresponding origin. This is followed, months or years later, by 
gradual loss of power, atrophy, and anesthesia in the corresponding 
parts, and as compression upon the cord is produced spastic symptoms 
appear below, with increased reflexes, rigidity, and paraplegia, leading 
sometimes to exhaustion and death. Some cases present stationary 
periods, and a few recoveries are claimed. The muscles of the forearm 
are not uniformly affected, the flexors being most impaired. This 
results in a peculiar deformity that is striking and almost characteristic. 
The small muscles of the hand usually suffer and both arms are com- 
monly affected, though not usually in equal degree. In many instances 
the cord shows the peculiar changes of syringomyelia, and the symptom- 
atology of this condition is then added to that of the pachymeningitis. 
The diagnosis is difficult when the dural involvement is of general dis- 
tribution and cerebral symptoms are present, as the spinal features are 
overshadowed. Diseases of the spine, progressive muscular atrophy, 
cross-myelitis, tumor, and external pachymeningitis must be excluded. 
An operation may be required to differentiate the external dural inflam- 
mation. It presents, except in syphilitic cases, the best chance of favorably 
influencing the condition and preventing destruction of the cord. In the 



( 



Fig. 101.— Position of hand in pachymeningitis cervicalis hypertrophica. 



desperate situation that is presented and with the courage given by 
asepsis, it may the more reasonably be resorted to early. Where syph- 
ilis is suspected, specific treatment should be persistently tried. 

Acute Spinal Leptomeningitis. — Acute spinal leptomeningitis, or 
inflammation of the pia mater, is due to infection. It usually involves 
the inner surface of the dura, and commonly extends to the peripheral 
substance of the cord. 

Etiology. — The infection of cerebrospinal meningitis, as in epidemics 
of the disease, falls sometimes only on the cord, and the infective nature 
of the attack is obvious. In those cases, however, that are attributed to 
exposure, insolation, rheumatism, and other occult conditions, the infection 
is less readily comprehended, but in all probability is equally in opera- 
tion, being favored by the physical conditions mentioned. In some recent 
cases the discovery of the pneumococcus and the meningococcus proves 
the identity of the infection with that of the cerebrospinal type, to which 
the reader is referred. The association of cases with septicemia, pyemia, 
and other infectious blood-states points again to infection, and in the 



DISEASES OF THE SPINAL MENINGES. 281 

lymph and spinal fluid of these cases abundant pathogenic organisms 
have been observed. In some instances the spinal disease is an exten- 
sion from the cerebral meninges, the cervical portion of the cord being 
usually the only part involved, but the entire clural sheath may be filled 
with pus from within the cranium. Traumatism of the membranes by 
vertebral dislocations, strains, and severe concussions may incite a lepto- 
meningitis over a limited area, from which it may extend, or in which 
a virulent infection may find a suitable field for development. Surgical 
operations upon the spine, penetrating wounds, sacral bedsores, and 
communication with adjoining suppurative foci may furnish the infection. 
Tuberculosis is a common cause, but the resulting meningitis is rather 
less acute. This is the case to a greater degree in syphilitic inflamma- 
tion, which has a marked tendency also to remain localized. 

Morbid Anatomy. — The disease is usually of wide extent, the 
infection traveling rapidly through the arachnoid spaces, and finding in 
the spinal fluid an excellent medium for its propagation and extension. 
Congestion of the pia, of the adjoining inner surfaces of the dura, and 
of the cord, marked by increased vascularization and an increase of 
spinal fluid, passes into inflammation, with dulness of the membranes, 
opacity, thickening, and an exudate, varying in color from opalescent to 
puriform, and of corresponding consistency. The microscope shows the 
diapedic elements of inflammation and often numerous bacteria, includ- 
ing at times the pneumococcus of Friedlander. Tubercles here corre- 
spond to their histological and bacterial characters on other serous 
surfaces. For a time the somewhat resistant pial covering of the cord 
and nerve-roots protects these structures, and especially is this true in 
the purulent form of the disease. Usually the periphery of the cord 
and the roots show the inflammatory invasion, with corresponding 
changes in the nerve-fibrils, neuroglial framework, and vessels. In 
cases reaching a convalescent or chronic stage, adhesions form between 
the cord and the dura, obliterating the arachnoid space over more or less 
extensive areas, distorting the nerve-roots, and sometimes changing the 
outlines of the cord itself. If cord-softening has taken place as a result 
of the meningomyelitis, degenerations of its conduction tracts and local- 
ized destruction of its gray matter are found. Large quantities of 
spinal fluid usually mark these late cases, causing, with the irregular 
adhesions, a sacculated condition of the dura. 

Symptoms. — The abrupt onset of the disease may be preceded by 
a day or two of malaise and slight anorexia, but sometimes no invasion 
period is present. A sharp chill is followed or attended by great pain 
in the back and darting pains around the body or down the limbs. In 
children vomiting is a common symptom, and convulsions may be pres- 
ent. Tenderness is at once developed over the spine. It is easily 
detected, when not prominent, by the use of a sponge dipped in hot 
water or by percussion. Spasm and rigidity of the muscles appear, 
pausing stiffness of the neck and back, sometimes notable retraction of 
the head and vigorous opisthotonos. Fixation of the limbs upon the 
body is more or less marked, with a tendency to flexed attitudes. 
Retraction of the belly results from implication of the abdominal mus- 
cles. Sometimes difficulty of breathing is occasioned by involvement 



282 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

of the chest muscles. Kernig's symptom is present. Dyspnea, Cheyne- 
Stokes respiration, and cardiac symptoms follow medullary implication. 
The cramps in the muscles are painful, and yet tenderness and hyper- 
esthesia in the limbs prevent manipulations and passive movements. 
The rectum and bladder are the seat of similar spasms, which may cause 
constipation and retention of urine, with frequent annoying and inef- 
fectual expulsive contractions of these viscera. 

Pulse and temperature are fickle, sometimes being subnormal, some- 
times increased, and more often divergent ; for instance, a subnormal 
temperature with an accelerated pulse. The lack of uniformity in their 
range is especially valuable in diagnosis, even when the cerebrum is 
apparently not involved. A temperature of 103° F. is not uncommon. 
Vasomotor paralysis is usually shown by the vivid, persistent, but 
slowly developed line which follows every stroke of the finger-nail 
upon the skin, and from the same cause the limbs may be congested 
and even slightly edematous. At first, for a day or two, reflexes are 
inclined to be increased and later may be wanting. 

Cases which outlast the acute symptoms develop paralysis, anes- 
thesia, atrophy, and contractures in proportion as the cord and nerve- 
roots are affected. Paraplegia may result, presenting the features of a 
cross-myelitis, with bladder-paresis, bedsores, increased reflexes, and 
spasticity. Symptoms vary with the location of the disease, but its 
tendency to involve the entire spinal apparatus is marked, and indica- 
tions of its effect upon all spinal segments are to some degree present 
in a majority of instances. Some regions situated in the focus of the 
inflammatory action show early and emphatic involvement ; those at a 
distance may be disturbed very little. Yet in some purulent cases, 
where the dural sheath is greatly distended through its entire length 
with the large accumulation, the pia protects the cord and nerve-roots 
from infection, so that pressure symptoms alone may be present. 

Course. — Some cases terminate fatally within a day or two ; others 
last a fortnight, and may then end fatally or recover. The nature and 
virulence of the infection are determining factors, as is the location of 
the disease. Extension upward or early involvement of the high levels 
of the cord tend to an early fatal issue. Complete recovery is rare and 
the conditions resulting from secondary myelitis are of long duration 
and usually last the life-time. The tubercular and syphilitic varieties, 
as already indicated, run their course less rapidly, and the latter is 
capable of material modification by treatment. Even rare tubercular 
cases may get well. 

Diagnosis. — The diagnosis depends upon the rapid onset, the pain 
in the back, the radiating pains, the rigidity, the increase of pain on 
voluntary movement, the hyperesthesia, and the fickle temperature and 
pulse. From myelitis it is distinguished by the paralysis and lack of 
pain which characterize the cord-lesion, but the frequent association of 
the two is to be kept in mind. Hemorrhage into the subdural space, 
owing to the irritation of the nerve-roots, presents very similar 
symptoms, but is extremely rapid in onset, usually following traumatism 
or a strain, and develops meningitis in a short time thereafter. Hem- 



DISEASES OF THE SPINAL MENINGES. 283 

orrhage into the spinal cord gives instantaneous symptoms, immediate 
paralysis, and may be practically devoid of pain. The rigid form of 
tetany may present a very close counterfeit, but its long duration, 
remissions, and amenability to spinal sedatives, the absence of spinal 
tenderness and shooting pains, the possible history of previous attacks, 
and the usual irritability from pressure upon the nerve-trunks and 
arteries should differentiate it. Tetanus may be mistaken for spinal 
meningitis. The early trismus, the excessive hyperesthesia, the fever 
of onset, the paroxysms of spasm, and the frequent history of traumatism 
point the way to diagnosis. Muscular rheumatism and strain present a 
very superficial resemblance. Spinal puncture and bacterial investiga- 
tion are always in order. 

Prognosis. — The outlook as to life is always serious and is grave 
in proportion to the acuteness of the onset, to the virulence of the in- 
fection, to the implication of the upper portion of the cord, and to .the 
height of temperature. The estimate is also to be guided by the 
previous condition of health and the age of the patient, children and the 
aged quickly yielding to the disease. Traumatic and surgical infection 
is less serious than auto-infection. The possibility of the removal of 
sources of infection is of some importance as to ultimate results, pro- 
vided the patient survives the acute stage. The late results, due, for the 
most part, to permanent changes in the cord, are usually beyond the 
hope of marked improvement. 

Treatment. — Complete and absolute quiet is to be insisted upon. 
The patient should be kept upon the side or face, if it is possible to do 
so without increasing the cramps. The partial knee-elbow posture 
over a mound of firm pillows will often be found very comfortable, and 
at the same time will afford the best opportunity for local applications. 
These, at first, should be count erirritant. Should myelitis be associated, 
less active measures are indicated, and the skin must not be broken or 
highly irritated, owing to the tendency to bed-sores. A hot bath and 
pack at the onset with active catharsis have seemed to do good. Seda- 
tives, especially spinal sedatives, are frequently required to control the 
spasms and anodynes to relieve the pains. A thorough course of 
mercurial inunctions over the spine has strong advocates, the quantity 
used being sufficient to produce slight ptyalism. Owing to the reflex 
irritability, these rubbings must often be impossible, and the therapeutic 
value of mercury in the acute stage of non-luetic cases is open to question. 
Quincke's lumbar puncture has here the same indications as in the 
cerebrospinal form. Flexner's serum should be used in all cases pre- 
senting the meningococcus. Iodid of potassium and ergot are of little 
or no value. The ice-bag to the spine is one of the most serviceable 
measures, but is rarely tolerated long by the patient, and its inter- 
mittent application is useless. It should always be tried. As the 
active stage subsides, light cauterizations with the Paquelin apparatus, 
mild sinapisms applied for six or eight hours, and the hot-spray douche 
seems to assist the reparative efforts of nature. Cerebral symptoms 
usually mean the implication of the brain-coverings, the spinal features 
become of secondary importance, and the treatment is that of cerebro- 



284 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

spinal meningitis. The paralysis, contractures, and other late results 
of the myelitis are to be managed in accordance with the rules of 
practice in that disease. 

Chronic Spinal Leptomeningitis. — The chronic form of inflam- 
mation of the soft spinal membranes is usually the sequential stage of an 
acute attack, but may follow alcoholism, syphilis, or tuberculosis. Its 
existence as a primary affection is open to some doubt, but a very slowly 
developed leptomeningitis may follow concussion, though it is impossible 
in such a case to exclude immediate slight histological injuries of which 
the later inflammation is a natural development. The formerly much 
used term " chronic meningitis," which was applied to every group of 
obscure subjective symptoms, however remotely referable to the spine, 
needs no mention. In tabes dorsalis there is almost invariably a chronic 
meningitis especially affecting the posterior portion of the membranes 
and the posterior roots. 

The symptoms are practically those of the acute form much reduced 
in intensity, and are dependent upon similar causes. Pain in the back 
predominates, and spasm is insignificant or absent. The radiating neu- 
ralgic pains are especially pronounced, and paresthesias are prominent. 
Their distribution depends upon the nerve-roots involved and the loca- 
tion of the inflammation, which is much more circumscribed than in the 
acute form. The late manifestations are those due to neuritis originat- 
ing in the roots, and myelitic symptoms are comparatively infrequent. 

The anatomy of the disease is very little known, as opportunity for 
post-mortem examination rarely occurs, but more or less extensive fibrous 
thickening, or adhesions between the pia and dura which constrict the 
nerve-roots, may be found, and may girdle the cord. Degeneration of 
the spinal nerves traversing the lesion is not rare, and this accounts for 
the herpetic and other cutaneous symptoms which are occasionally noted. 

The prognosis will be guided mainly by the effect of treatment, but 
a complete recovery is very rare. Each case must be carefully estimated 
by itself. 

The treatment in syphilitic cases consists in the heroic management 
of that disease, and iodids and mercury in small doses are also the most 
efficient drugs in non-luetic cases. General measures are of service, and 
persistent counterirritation over the spine, preferably by Paquelhr's 
cautery, is the most valuable local measure. Sometimes rest in bed 
and the ice-bag to the spine are of distinct value. Sedatives and 
analgesics are often required. 

Spinal Meningeal Hemorrhage. — Spinal meningeal hemorrhage 
is either extradural^ in the vertebral canal, or subdural, within the dural 
sheath. It is frequently associated with intracranial hemorrhage and 
with hemorrhage into the substance of the cord, but also occurs inde- 
pendently. 

Etiology. — Meningeal hemorrhage occurs frequently at birth in 
protracted and difficult labors, and is then almost invariably associated 
with extensive hemorrhage within the skull. It has been considered 
under the cerebral palsies of childhood. Spontaneous hemorrhage is 
very rare, but occurs in adult life at all ages. Disease of the meningeal 
vessels is sometimes the immediate cause, but in the great majority of 



DISEASES OF THE SPINAL MEXIXGES. 285 

cases it is induced by traumatism. It may be caused by direct blows 
or falls upon the back, shock communicated through the lower limbs, 
vertebral fractures and dislocations, penetrating wounds and even by 
severe muscular spasm, as in tetanus, convulsions, and violent chorea. 
No doubt syphilis, arteriosclerosis, purpura, scurvy, and other hemor- 
rhagic states favor it. The blood sometimes comes from a thoracic aneur- 
ysm winch has eroded the vertebrae and ruptured into the spinal canal or 
dura, or from one situated on the vertebral or basilar arteries. Hem- 
orrhage into the cerebral meninges may find its way below the foramen 
magnum, and in the same way a spinal hemorrhage may invade the 
cranium. 

Morbid Anatomy. — In extradural cases the clot usually originates 
from the rich plexuses of veins that line the vertebral canal. It may 
be of considerable size and extend through the intervertebral foramina. 
The most common location is in the cervical region. The dura is 
stained and infiltrated, and the cord may exceptionally be compressed. 
Effusions of blood within the dura vary much in size. The blood usu- 
ally comes from the pial vessels, and consequently, as a rule, involves 
the cord. Complete flooding of the dural sheath is almost always due 
to intracranial hemorrhage or rupture of an aneurysm. A small hemor- 
rhage tends to remain localized and to surround the cord at the original 
point. It discolors and compresses the cord and after a few days pro- 
duces inflammatory changes in the meninges. In the same way an 
annular myelitis may be induced. 

Symptoms. — The symptoms are practically the same in both extra- 
and subdural hemorrhage The onset is ordinarily abrupt and the early 
symptoms depend upon irritation of the meninges and nerve- roots. 
There is great pain in the back, which often radiates along the impli- 
cated nerves, girdling the body or running down the extremities. Tin- 
gling and formication are complained of, and paralytic symptoms below 
the level of the lesion, loss of power, and diminished sensation are induced. 
Bladder and bowel symptoms shortly appear. There is ordinarily some 
spinal rigidity, which may develop into opisthotonos, and convulsions are 
not infrequent. Symptoms are promptly developed. In crushing in- 
juries, spinal fractures, and dislocations the cord is almost invariably 
injured, and hemorrhage, if present, adds very little to the symptoms. 
From the onset to the full development of the paralytic features from 
one or two to forty-eight hours, or even more, may be required. The 
symptoms then greatly resemble those of spinal meningitis, which 
usually is added after a few days, and its invasion is often marked by 
a distinct aggravation. 

Cerebral symptoms are only present when the cranial contents are 
simultaneously affected. Death is likely to occur early when the symp- 
toms have reached their height, or during the secondary meningitis. 
Hemorrhage in the cervical region is strangely and promptly fatal. 

Diagnosis. — In cases of insidious onset without definite symptoms, 
the diagnosis at best can be but conjectural. "When hemorrhage follows 
traumatism, the distinguishing trait is a gradual development of the 
symptoms within a few hours. Injuries that affect the cord substance 



286 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

produce instantaneous loss of function, but a meningeal hemorrhage 
may be, and often is, associated with hemorrhage into the cord. Jacobi 
has also obtained blood by spinal puncture in two cases of injury of the 
spine. 1 From meningitis the chief distinction is the mnch more rapid 
development in hemorrhage and the history of a competent cause. The 
localizing diagnosis is taken up in subsequent chapters, to which the 
reader is now referred. 

Prognosis. — The outlook is always most serious. As the paralytic 
features develop, there is a likelihood of death from interference with 
respiration by paralysis of the chest-muscles. The intense pain and 
suffering also serve to exhaust the patient. The first danger being 
passed, secondary inflammation is likely to terminate the case fatally. 
Hemorrhage in the cervical region is, of course, more ominous than 
when situated lower down. If the patient survives the first fortnight, 
improvement may be confidently expected, and this may practically be 
complete, though some disability remains, as a rule, and it may be of an 
extreme degree. 

Treatment. — At first the most complete rest on the face or side with 
the spine elevated should be secured. An ice-bag to the back is a valu- 
able measure if persistently and thoroughly used. Venesection to lower 
the blood-pressure has been used, but will not find many brave enough 
to employ it. Local wet cups with free flow of blood have also been 
employed, but are of doubtful value. Remedies that increase the coagu- 
lability of the blood may be exhibited, but ordinarily the flow of blood 
is of but a few moments' duration, and no time is given for their action. 
If the diagnosis is fairly certain, the spinal canal should be aseptically 
opened and the dural sheath also incised. The operation as now done 
adds nothing to the gravity of the case, and has enabled the surgeon to 
remove clots with the best results. The secondary meningitis and the 
sequential palsies are to be treated on their own indications. 



CHAPTER II. 

INJURIES AND DISEASES OF SPINAL NERVES, 

The spinal nerves, unlike most of the cranial group, are both motor 
and sensory. In addition, they contain the vasomotor supply, and 
through them is exerted the trophic influence of the spinal centers over 
the peripheral apparatus. Their injury or disease is, therefore, marked 
by perversion or abolition of these functions, and gives rise to groups of 
symptoms anatomically coextensive with the distribution of the par- 
ticular nerve or nerves involved. We should bear in mind that the fibers 
making up a nerve-trunk are cellular elements, — prolongations from 
cell-bodies, of which they form an integral and functionally essential 
part. When we injure a motor fiber in a nerve-trunk we injure a motor 
cell. In other words, we injure the lower motor neuron. We will first 
consider nerve injuries and diseases in a general way, and then the 
particular conditions which pertain to such states in special nerves. 
1 "Amer. Jour. Med. Sciences," Oct., 1900. 



INJURIES AND DISEASES OF SPINAL NERVES. 



287 



Division of Nerves. — Spinal nerves are frequently divided by 
incised and bullet wounds, sometimes by crushing accidents, by simple 
and compound fractures, and rarely by dislocations. Causes acting 
more slowly may end in the destruction of a nerve, but a neuritis or 
degeneration is usually, if not always, first induced. After a nerve is 
divided the peripheral portion degenerates, and the process is called 
secondary degeneration. 

The immediate symptoms are loss of motion, sensation, and muscular 
reflexes in the distribution of the nerve. Shortly afterward, within 
forty-eight hours, the muscles 
supplied by the injured nerve 
lose their tonicity and then pro- 
gressively waste. Vasomotor par- 
alysis appears and trophic dis- 
turbances in the cutaneous area 
of distribution are marked by a 
thin, shiny skin, with atrophic 
hairs, nails, and other epithelial 
structures. There is also a low- 
ered vital resistance to infection, 
and healing processes are slow 
and faulty. Even the joints are 
sometimes affected, and bony 
growth in the young is retarded 
Electrical stimulation through 
the nerve fails completely. The 
muscles lose their responsiveness 
to farad ism, and the increased 
galvanic irritability which at first 
appears gradually subsides and is 
finally lost. The electrical changes 
constituting the reaction of degen- 
eration are more fully described in 
Part I, page 46. In the extremi- 
ties the unopposed antagonist mus- 
cles then draw the joints into 
fixed, rigid positions. Muscular 
contractures develop and still fur- 
ther tend to deform the part. 

The histological changes that take place in the distal portions of the 
divided nerve are as follows : The nuclei of the internodal nerve-cells 
swell, and their protoplasm becomes increased in quantity, but changed 
in character, as it no longer stains so actively as in health. The nuclei 
also become segmented, and with the increase in protoplasm encroach 
upon the myelin and displace it. The nerve-fiber then shows an 
irregular beading of the myelin, and at the points of greatest constric- 
tion the myelin finally separates transversely, and the axis-cylinder 
is divided at the same time and in the same way. This process takes 
place uniformly throughout the length of the divided nerve below the 



ABC 

Fig. 102. — Xerve tubules in peripheral portion of 
a divided nerve — A, two days after section ; B, four 
days after section; C, eight days after section. 1, 
Sheath of Schwann; 2, myelin ; 3, nuclei; U, proto- 
plasm (Ranvier). 



288 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

lesioiio The segmented myelin becomes more and more aqueous, escapes 
in part through its sheath, and is absorbed. The nuclei cease prolifera- 
tion, and the nerve-fiber is left a mere connective-tissue filament, except 
at irregular intervals, where remaining globules of myelin may distend it. 

The segmentation of the myelin in man reaches the point of complete 
division and consequent rupture of the axis-cylinder at about the end 
of the third day after nerve-division. At this time electrical conduc- 
tion or excitability in the nerve is also lost and muscular tonus is 
destroyed. The entire process of degeneration after nerve-division may 
be completed within three weeks. 

Above the point of division the central stump degenerates for about 
a third of an inch only, .but there is reason to believe that the cell-body 
is also disturbed (Marinesco). 

The muscles supplied by a divided motor nerve are deprived of the 
trophic influence of the spinal center as soon as division takes place, and 
the axis-cylinder below the lesion is equally deprived of the trophic 
support of the cell-body. The sarcode elements waste. The cross stria- 
tions become less well marked and are closer together ; the muscle-fibers 
become narrowed, cloudy, granular, and sometimes fatty. There is pro- 
liferation of the connective-tissue elements of the muscles, which further 
strangulates the muscle-cells, and eventually a condition of fibrosis or 
cirrhosis is developed. This has a natural tendency to contract and 
shorten, and explains the fibrous, tense, cord-like structures and deform- 
ities found in such cases of long standing. 

The electrical changes that occur in the muscle are also described in 
Part I, page 46. Faradic muscular contractions are lost within a few 
days, but at first, for about a week, the muscles react to galvanism even 
more freely than in health ; then the galvanic excitability of the muscle 
is diminished and disappears. 

When the ends of a divided nerve are brought together under proper 
conditions for healing, regeneration may occur in the peripheral portion 
even when degeneration is complete and of long standing. Bowlby has 
noted one case of regeneration after fourteen years' division. In nerves 
freshly divided and at once united, the functions of the nerve are 
restored in a few days or weeks. After degeneration has been estab- 
lished regeneration is a slow process, requiring from two months to 
several years, depending upon the condition of the peripheral segment and 
the surgical features of the given case. According to Tizzoni, Kennedy, 
Bethe, Ballance, and Stewart, 1 regeneration in a divided nerve is depen- 
dent upon proliferation of the neurilemma cells. At the end of three weeks 
spider-like neuroblasts are seen sending out beaded axis-cylinder processes 
in both directions from opposite poles. At the end of the fourth week 
these processes may overlap and anastomose. A new medullary 
sheath appears about the eleventh week. Neither axis-cylinder nor 
medullary sheath attains full maturity unless the distal segment is 
joined to the proximal nerve-stump. Non-myelinated nerves, as, for 
instance, cerebral conduction tracts, do not regenerate, lacking the 
necessary cellular elements required for that process. The muscles, in 
turn, regenerate, and slight volitional motion returns before electrical 

1 Macmillan & Co., 1901. 



INJURIES AND DISEASES OF SPINAL NERVES. 289 

responses can be obtained with the usual tests. These appear, as a rule, 
shortly after voluntary power is manifested, and while it is still very 
slight. Sensory conduction is usually restored before muscular action. 
The muscle reflexes are the last to reappear. 

It need scarcely be added that the only treatment for a divided nerve 
is surgical suture. Whenever the distal extremity can be aseptically 
united to the central end, and in proportion as it is done promptly after 
the division, the prospects for a return of function are good. In cases 
marked by degeneration, electrical stimulation should be early and per- 
sistently employed, even if no motor response is obtained. In cases of 
long standing and in instances where it is impossible to effect nerve 
suture, the implantation of the distal segment into a neighboring nerve 
of similar function is frequently followed by a return of functional and 
volitional control. 

Neuritis. — Peripheral nerves are subject to inflammatory action of 
every grade of severity, arising from an extraordinary number of causes. 
Many toxic conditions and cachexia cause widely distributed and 
usually bilateral symptoms, due to degenerative states in the peri- 
pheral nervous apparatus, producing a so-called multiple neuritis, the 
consideration of which is reserved for a separate chapter. We have 
here to deal with a nerve inflammation or degeneration arising from 
local causes. The particular cause, however, may be the topical feature 
of a systemic disease, as when a nerve is involved in a syphilitic tumor 
or a gouty, nodular thickening. Consequently the lesion in question is 
confined to one nerve or to several that are anatomically related. 

Etiology. — Slight compression or contusion may cause temporary or 
persisting disturbance in the function of nerve-trunks, — a fact made 
familiar by knocking or pressing upon the ulnar at the elbow or by 
pressing on the sciatic in sitting. If the compression or contusion is of 
sufficient severity, the nerve may be an indefinite time in recovering, and 
long-continued pressure or extreme contusion may, like actual division, 
induce a complete degeneration. Dislocations, fractures, the formation of 
callus, violent muscular contractions, strains, cramped positions or con- 
tinued pressure in sleep, coma, surgical anesthesia and extreme prostration, 
pressure from the continued use of surgical appliances, crutches, trusses, 
and constricting shoes or garments are among such causes. A nerve 
may be wounded or infected in surgical and accidental ways, and by the 
hypodermatic needle. It may be invaded by extension from a neighboring 
inflammation, as in arthritis, pleurisy, meningitis, bedsores, abscesses, 
or any other inflammatory focus. Exposure to cold is especially active, 
as in the facial nerve and others that are superficial or contained in 
rigid canals and passages. New growths, like cancer and gumma, and 
infiltrations in leukocythemia, cancer, leprosy, and syphilis may cause 
a neuritis. 

There are also a number of predisposing causes, some of which are 
active in the etiology of multiple neuritis. Here may be enumerated 
gout, rheumatism, diabetes, exposure to cold, alcohol, lead, and cachexias 
generally. In such conditions an exciting cause acts more readily and 
repair takes place more tardily. 

Morbid Anatomy. — The anatomical changes in a neuritis vary 

19 



290 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

according to the intensity of the process and the particular elements 
in the nerve-trunk that are most affected. When the nerve-fibers are 
mainly involved, Ave speak of a parenchymatous neuritis. This form is 
rarely secondary to a local injury, but sometimes so arises. It is the 
common form in the multiple neuritis of systemic states. When the 
fibrous structure of the nerve-trunk is most affected, the neuritis is 
called adventitious. In the case of inflammatory extension from adjoin- 
ing structures the sheath or surface of the nerve is usually first involved, 
and the condition is then distinguished as a perineuritis. 

An acutely inflamed nerve looks reddened and presents increased 
vascularity. There is sometimes distinct edema, or a jelly-like infiltra- 
tion of the sheath and adventitia may be seen. This is ordinarily con- 
fined to a limited extent of the nerve, or may be seen at numerous 
points. It is particularly likely to be present where the nerve is super- 
ficially placed over firm structures, as where a nerve passes over bony 
prominences or is tightly enveloped in fascial or bony tissues. From 
pressure or irritation thus arising, changes of corresponding degree take 
place in the nerve-fibrils. When the neuritis or even the contusion is 
sufficiently severe to disrupt the myelin for a few hours, we have a 
descending degeneration below the lesion, which then presents the morbid 
appearances described in nerves after complete division. In the case 
of neuritis, however, it is common for some fibers to escape, and to appear 
practically normal in the cross-section of the degenerated nerve. 

As a rule, the inflammatory and degenerative process is confined to 
the injured portion of the nerve and the parts beyond, but occasionally, 
and then usually in the case of infected wounds, the neuritis extends up- 
ward, and if it reaches the plexus of origin may there involve other 
nerve-trunks related to it. This ascending form is sometimes called 
neuritis migrans. In cases of long standing the adventitia is increased 
and a fibrous thickening of the nerve may result, which persists even 
after restitution of function has taken place. In unrecovered cases the 
degenerated nerve may be reduced to a mere fibrous filament. 

Infiltration in syphilis and cancer is identical with these processes 
elsewhere, and may cause distinct tumors in or on the nerves. In 
leukocythemia and leprosy there is merely an infiltration, which in 
the latter may contain the characteristic bacilli. Perhaps the same 
may be true in neuritis arising from tubercular ulcerative lesions. 

Symptoms. — The symptoms of neuritis vary greatly. They may be 
mainly those of irritation or those of destruction of the conducting func- 
tions of the nerve-fibrils. Ordinarily both are present. Local condi- 
tions at the point of original nerve injury, such as swelling, contusion, or 
laceration, may be added. The onset is ordinarily abrupt, in the case of 
traumatism instantaneous. When the nerve is insidiously invaded the 
symptoms develop with corresponding slowness. The sensory disturb- 
ances are usually the most prominent at first. All varieties of paresthe- 
sia are complained of: Formication, numbness, tingling, burning, heavi- 
ness, deadness, coldness, etc. There is considerable pain in severe cases 
at the site of inflammation, and in the muscles and skin to which the 
nerve is distributed. The nerve-trunk and the supplied muscles are 



INJURIES AND DISEASES OF SPINAL NERVES. 291 

usually tender on pressure. The nerve tenderness is particularly promi- 
nent where the trunk is rigidly held by fibrous tissues or passes over 
bones. The nerve may sometimes be palpably enlarged. Pressure 
upon it by muscular action may also elicit tenderness and increase the 
pain. The cutaneous area of its distribution presents hyperesthesia or 
diminished sensitiveness, or both. Often there is a feeling of painful 
sensitiveness when tactile perception is actually blunted. After degen- 
eration starts in the nerve, anesthesia is present in the skin supplied by 
the nerve, though irritation at the site of original lesion may still lead 
to complaints of peripheral pain, constituting anesthesia dolorosa. The 
striking feature of all these sensory disturbances is their constancy 
and uniformity in a given case. Stabbing pains and momentary pares- 
thesia are wanting. As the inflammation progresses the conductivity of 
the nerve decreases, hyperesthesia becomes anesthesia, and paresis passes 
into paralysis. The anatomical distribution of the sensory features is 
very important. Often it can be mapped out with the greatest pre- 
cision, but at first usually the margin of the area of disturbed sensation 
is not so sharply defined and the entire limb may be painful and sensi- 
tive. 

The paralytic muscles are those which are supplied by the given 
nerve. Opposing muscles may lack force from the loss of proper bal- 
ance, or their use may be inhibited by pain. Delicate finger-motions 
are rendered clumsy by the sensory disturbance or the loss of power, 
or by both combined. 

If the lesion be sufficiently severe to set up degenerative changes in 
the nerve, we find the trophic losses in the skin and muscles described 
under Division of Nerves, page 287. These may be, and often are, present 
in a modified degree when motor and sensory functions are not com- 
pletely gone. In all cases of long standing they are sure to appear. 
With them go the various other symptoms already described : the loss of 
muscle reflexes, the electrical changes of irritation, degeneration or destruc- 
tion, and the development of contractures. In complete division of 
nerves the nutritional disturbance is usually a simple atrophy, but in 
neuritis there is a wider range of dystrophic conditions. These are 
most marked in the hands and feet and most apparent in the dermal 
structures, though the muscular wasting is sufficiently apparent and often 
most striking. In some cases there is much obscuring edema, due to the 
lack of vascular and muscular tone. In these cases and in those in 
which redness and profuse perspiration are present, the dermal epithelium 
and the hairs and nails often take on an excessive growth. As a rule, 
the nails become roughened, scaly, and strongly curved. The cushions 
at the tips of the fingers waste and the nails may curve over toward 
the palmar surface, like claws. About the base of the nails the skin is 
often thin, glazed, and red, and the entire digit may be reduced to a 
tapering, stick-like appendage, closely covered with atrophic skin, which 
no longer shows the natural folds and wrinkles about the articulations. 
Abrasions do not heal readily. Herpetic eruptions are likely to appear, 
and deep ulceration may follow unless unusual care be exercised to pre- 
vent irritation and infection. In some cases the nails are cast off. 



292 DISEASES OF SPINAL 3IENINGES AND SPINAL NERVES. 

From inaction and the tendency to contracture in atrophied muscles 
and their unapposed antagonists, the range of joint-motion in chronic 
cases is usually diminished. Trophic disturbances in the joints are also 
encountered, with the formation of adhesions, and false ankylosis. In 
rare cases joint-effusion and other neurotic arthropathies have been seen. 

Should the neuritis ascend to the plexus and implicate other nerves, 
similar conditions are induced in their peripheral parts. 

Diagnosis. — The diagnosis of a neuritis presents usually but little 
trouble. If the dysesthesia be confined to the anatomical limits of a 
given nerve or group of nerves, and the muscular disability is limited 
to the muscles innervated by the same nerve, the conclusion is obvious. 
Too much importance can not be given to the study of the cutaneous dis- 
tribution of the sensory disturbance. If this area corresponds with that 
of any special nerve (see Figs. 15 and 16), suspicion of a neuritis or 
nerve injury should be at once aroused. If the corresponding reflexes are 
gone, or in slight and rare instances are even exaggerated, and if the 
degenerative or irritative electrical responses are present, the suspicion 
is confirmed. Sensitiveness of the paralytic muscles and of the sup- 
plying nerve-trunk are also important indications, and occasionally the 
thickened nerve can be felt. A wound or contusion over the nerve is 
of capital significance. The question often arises in traumatic cases as 
to whether the nerve has been completely divided. If the reaction of 
degeneration is present three or four weeks after the injury, the nerve is 
not totally divided. In the case of division no electrical responses are 
obtainable after a month. Many cases of neuralgia are confounded 
with neuritis. The distinction depends mainly on the darting, fleeting, 
changing character of neuralgic pains and the presence of the painful 
points of Valleix. Muscular wasting or electrical changes and altered 
reflexes demonstrate a neuritis. 

Prognosis. — The course of a neuritis depends upon its cause and 
the amount of damage done the axis-cylinders of the nerve. The gen- 
eral tendency is to restoration of healthy function as soon as the cause 
is removed. A slight neuritis may pass away within two or three weeks, 
but if the lesion has resulted in degeneration of the nerve, months will 
be required for the regenerative process. The faradic muscle responses 
afford a good basis for estimating the probable duration of a case. If 
the muscles contract fairly to a moderate current two weeks after an 
acute attack, the disease will probably not last over a month or two. If 
they do not respond to a strong faradic shock, six to nine months will 
be required. In long-standing cases the persistence or reappearance of 
faradic excitability is a favorable sign for complete recovery. On an 
average, traumatic cases do better than those arising from extending in- 
flammations, especially if they are of a septic character. Should there 
appear an upward extension of the neuritis the outlook is less favorable. 
The presence of any predisposing cause also diminishes the prospect of 
early recovery, and when the neuritis is due to a new growth the prog- 
nosis is unfavorable except in syphilitic cases. 

Treatment is naturally first directed to any discoverable cause, and the 
predisposing conditions must not be neglected. Gout, rheumatism, lead 



IXJUBIES AND DISEASES OF SPINAL NEBVES. 293 

infection, nephritis, diabetes, tuberculosis, the use of alcohol, the presence 
of anemia, malaria, or any cachexia must be corrected as far as possible, and 
the general physical health brought to its best level. "Wounds, septic in- 
flammations, and new growths require surgical intervention. Pressure by 
crutches, clothing, and surgical appliances must be discontinued. Pain is 
ordinarily the most pressing complaint. It must be controlled as far as 
possible by securing complete rest, in severe cases by immobilizing the 
parts. Muscular action, rude massage, and vigorous electrical stimulation 
produce pain, work harm, and should be avoided. On the other hand, 
gentle passive movements and muscle kneadings that do not cause dis- 
comfort, repeated daily or twice daily, are of distinct service in main- 
taining the nutrition of the parts that are temporarily deprived of 
their proper innervation. To this end the employment of electricity 
should be instituted, if possible from the first day. Ordinarily the gal- 
vanic current should be used, as it is least painful and most active. 
Only slight muscular contractions should be produced, and fatiguing 
the muscles must be avoided. If the faradic coil can be used without 
causing pain and the muscles respond to it, there is no objection to its 
use. The purpose to be kept in view is to maintain the responsiveness 
of the muscles to their weakened innervation, or, if that is cut off, to 
maintain them in the best possible nutritional and responsive state for 
the return of the slightest influence of the spinal cord that is able to 
first reach them through the blocked conduction of the injured nerve. 
These local measures also serve to overcome, so far as may be, the vaso- 
motor and trophic disturbances in the skin. 

The use of anodynes calls for mature judgment. They should be 
postponed to the latest moment, as in cases demanding them a protracted 
attack is commonly in hand and the danger of installing a drug habit is 
very great. Connterirritation by sinapism, thermocautery, or small 
blisters over the nerve is useful in the early stages if it can be made 
reasonably near the point of inflammation. It should never be made 
in the cutaneous areas snj^plied by the affected nerve, as it is likely to 
produce uncontrollable ulceration. 

In chronic cases massage, douching with hot and cold water, elec- 
tricity, and counterirritation are of great value. Strychnin in large doses 
and hypodermatically sometimes is of use. The use of iodids or of mer- 
cury is of questionable utility unless indicated by constitutional conditions, 
though mercurial inunctions along the course of the nerve have seemed 
to assist in some refractory cases. Contractures and distorted joints 
should be treated orthopedically. Muscles that are wasted and weak- 
ened may be of some service if not placed at complete mechanical dis- 
advantage by flexed joints and overacting, strong antagonists. Dropped 
foot, dropped wrist, flexed knee, and flexed hip should be obviated by 
early and persistent attention, by massage, and, if need be, by splints 
and fixation apparatus. Secondary contracture sometimes appears in 
the muscles of the extremities after regeneration of nerves injured by 
neuritis, just as it does in the face, but the balance is less delicate and 
distortion does not result so readily. 

Nerve-tumors. — Spinal and cranial nerves may present new 



294 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

growths of various sorts. In one group may be included those 
neoplasms which are common to all tissues, such as fibroma, myxoma, 
sarcoma, tubercle, syphiloma, carcinoma, etc. To another we should 
restrict those nerve-growths made up largely of nerve-fibers or nerve- 
cells, and these only may properly be called neuromata. In addition 
there are mixed and transition forms. In the first group the tumors 
are commonly secondary and usually single. In neuromata the tumors 
are commonly multiple and the condition is often hereditary and may 
be congenital or may follow traumatism. 

Of neuromata a number of varieties are encountered which have 
received descriptive names. Those made up of ganglion-like cells are 
called ganglion or cellular neuromata. When the nerve-fiber elements 
are present the term, fibrillar neuroma is used, and this is further divided 
into the myelinic and amyelinic sorts, depending upon the presence or 
absence of the myelin constituent. The adjectives terminal, central, 
peripheral, multiple, telangiectoid, and cirsoid are merely descriptive of 
location or form. 

Certain terminal neuromata which seem to be greatly enlarged 
Pacinian bodies constitute very painful tubercles under the skin, and to 
these the term neuromata dolorosa has been applied by Virchow. 

The multiple neuromata constitute an important group. In some 
cases they number thousands, and vary in size from small peas to 
masses as large as a fist. They are located in three general ways : (1) 
They may appear along a single or along several nerve-trunks at somewhat 
regular intervals, like beads ; (2) they may appear only on a single 
nerve and its branches, and (3) they may invade nearly every nerve 
in the body, including the sympathetic. In subcutaneous situations 
they appear like vascular, cirsoid dilatations, but present a different 
consistency and anatomical position, and are not modified by pressure 
on venous or arterial channels. They are most frequently acellular 
and devoid of myelin. While they may be sensitive and attended 
by neuralgic pains, they are usually unmarked by any sensory dis- 
turbance. As above indicated, such cases are sometimes of a heredi- 
tary nature. 

Traumatic neuromata are rather common and their frequency after 
surgical operations has given rise to the term amputation neuroma. A 
nerve involved in scar-tissue by the healing process is likely to develop 
such a neuroma. In amputated limbs the nerve-stumps become clubbed, 
and upon examination there is found an increase in the nerve-fibers and 
axis-cylinders, which have a tendency to turn up and twist about in the 
small tumor, the size of which is relative to that of the nerve on which 
it develops. It appears to be but the thwarted natural effort of the 
central portion of a divided nerve to extend downward. Such trau- 
matic neuromata are often exquisitely sensitive and may prevent the 
use of artificial limbs, besides causing much neuralgic suffering. 

Neuromata in the limited sense of the term are benign growths, but 
occasionally after irritation or partial surgical removal sarcomatous con- 
ditions appear. From their number, and rarely from their position, as 
within the vertebral canal or cranium, or on the pneumogastric nerve, 



INJURIES AND DISEASES OF SPINAL NERVES. 295 

they may prove fatal. True neuromata are often associated with skin 
tumors and cutaneous brownish circumscribed pigmentations. Preble 
and Hektoen 1 from the clinical side divide cases of multiple neuromata 
into four groups which may be variously combined in a given individual : 
(1) tumors of the skin, (2) tumors of the nerves, (3) pigmentation of the 
skin, (4) functional disturbances. 

Etiology. — In traumatic neuromata, and especially the amputation 
variety, the causation is readily understood. So is the action of irritation 
resulting in a fibrous proliferation which may strangle the nerve-fibrils, 
thrust them asunder, or locate a fibroid thickening on or within the nerve- 
sheath. The hereditary features of multiple neuromata do not explain the 
initial liability to this affection. They also appear in myxedematous, creti- 
noid, and phthisical conditions, and, strangely, are almost confined to males. 

Symptoms. — Neuromata manifest themselves by local signs and 
by motor and sensory symptoms in the distribution field of the invaded 
nerves. When situated on the nerve-trunk they may present much the 
same features as a chronic neuritis or local nerve-injury. Hyperesthesia, 
paresthesia, and motor and trophic loss are likely to appear with the elec- 
trical formula of degeneration. If the neuroma is open to palpation, it 
presents usually a rounded, dense, nodular, more or less sensitive swell- 
ing. Owing to its attachment to the nerve it has considerable lateral 
movement, but resistance is encountered in the opposite direction. 
Pressure sometimes provokes neuralgic pains or tingling in the sensory 
distribution of the nerve. Multiple neuromata, however, may be 
quite insensitive and present no sensory, motor, or trophic disturb- 
ances. They are only to be detected by the often visible chains of 
nodular enlargements along the course of the nerves. Traumatic neu- 
romata usually can be readily palpated in the region of scars and give 
a feeling of shot-like bodies which are usually very sensitive. The 
rare, painful tubercles constituting the neuromata dolorosa variety are 
readily palpated and give rise to pain and tingling in the definite nerve- 
area allied to their anatomical location. In some instances neuromata 
have caused muscular spasm in their neighborhood, or even at some 
distance, and epileptiform convulsions have been cured by their re- 
moval. 

Diagnosis. — Neuromata are readily diagnosed when a palpable, 
sensitive enlargement is found on a nerve-trunk with sensory and motor 
disturbance below. In cases of multiple neuromata the diagnosis is 
apparent. When single and deeply situated, their presence may only 
be inferred by the slowness of the onset of symptoms and the very 
chronic course of the disease. At the same time neuritis and pressure 
upon the nerve from adjoining new growths must, if possible, be 
excluded. In this case, also, it will be impossible to decide whether 
the growth in the nerve belongs to the first group or is a true neuroma. 
Multiple neuromata, traumatic neuromata, neuromata dolorosa, and neu- 
romata occurring in myxedematous individuals are usually of the true 
and, hence, benign variety. 

Prognosis. — Single neuromata are more likely to damage the nerve 
1 "Amer. Jour. Med. Sciences/' Jan.. 1901. 



296 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

than the multiple variety. If the tumor is of some size and functional 
disturbance is absent, none is likely to develop, but if such symptoms 
occur, they are likely to increase. True neuromata are of slow develop- 
ment and present a long course. Malignant or specific growths in nerves 
present the same outlook as elsewhere. 

Treatment. — The treatment of neuromata is practically surgical. 
They must be excised with as little damage to the nerve-trunk as possi- 
ble. In the multiple forms surgical interference is hardly practicable 
except for isolated masses, or to relieve special nerves. If the tumor is 
confined to the nerve-sheath, it may be removed without much injury to the 
nerve-trunk, bat if this is involved, the neuroma must be exsected and the 
ends of the nerve sutured. This is now accomplished even when several 
inches of the nerve are removed, by interposing pieces of nerves removed 
from animals, or by catgut bundles, bone tubes, etc. There is, however, a 
decided liability to recurrence of neuromata after surgical interference, due 
to the preexisting tendency and the irritant conditions set up by operation 
and healing. Nerve-stretching is claimed to be more efficient in relieving 
the reflex spasms than exsection. The use of anodynes for the relief of 
the neuralgic pains that sometimes make life burdensome should never be 
resorted to if the neuroma can be surgically dealt with. Pressure on the 
nerve above the tumor sometimes gives temporary relief from pain. 



LESIONS OF SPECIAL SPINAL NERVES. 297 



CHAPTER III. 
LESIONS OF SPECIAL SPINAL NERVES. 

Any spinal nerve may be singly injured by trauma or disease, or 
several neighboring nerves may be involved at the same time by local 
conditions. Such lesions give rise mainly to disturbance of sensa- 
tion, motion, and trophic control, showing themselves in varying 
degree in the cutaneous and muscular distribution of the injured nerves. 
The changed electrical conditions and the modified muscle reflexes that 
are also present equally depend upon the extent and nature of the lesion. 
These common lesions are division, neuritis, degeneration, and new 
growths, which have been considered in general terms in the preceding 
chapter. Irritant lesions produce morbidly exaggerated functions, such 
as spasms, hyperesthesias, pain, and rarely hypertrophy, while destructive 
lesions are marked by conditions of deficit, anesthesia, paralysis or 
paresis, dystrophy, and atrophy. These are often blended in the same 
case, as by the partial division of a nerve, or by a neuritis affecting mainly 
the motor or sensory portions of the nerve. For the sake of brevity, 
and to avoid repetition, these various nerve-lesions will be described 
systematically : (1) As to commonly acting causes ; (2) as to the resulting 
motor disability and deformity, and (3) as to the sensory disturbance. 
A lesion of a disabling degree will be understood to be in operation 
unless otherwise indicated. Lesser injuries will, of course, present 
relatively diminished symptoms. In some otherwise intractable neural- 
gias the posterior spinal roots have been divided surgically within the 
spinal column, the resulting anesthesia being insignificant unless at 
least three consecutive roots are cut. 



THE CERVICAL AND BRACHIAL PLEXUSES. 

The phrenic nerve, arising from the third, fourth, and fifth cervical 
nerves, is impaired : (1) By disease of the cervical vertebrae or of the 
meninges or of the cord, affecting its spinal nuclei or roots. The con- 
dition is then usually bilateral, and other muscles than the diaphragm 
commonly suffer. (2) In the neck penetrating wounds may reach this 
nerve, or new growths injure it. (3) In the thorax tumors may com- 
press it and inflammations extend to it. 

The resulting motor loss consists of inactivity of the diaphragm on 
the affected side, which fails to descend on inspiration, and the corre- 
sponding portion of the abdominal wall does not advance equally with 
that of the sound side. This is especially noticeable on deep inspiratory 
efforts. When both phrenics are involved, the breathing is of a costal 
sort, and any exertion quickly causes respiratory distress. Difficulty in 
expectoration, sneezing, defecation, and other abdominal expulsive efforts 
is also present. 



298 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

The sensory disturbance is obscure and often overlooked or miscon- 
strued as intercostal neuralgia, muscular rheumatism, etc. 

The posterior thoracic iu its long course from thefifth, sixth, and sev- 
enth cervical nerves to its distribution in the serratus magnus is often sub- 
jected to mechanical pressure from heavy objects carried on the shoulder 
and by muscular compression in severe exertion or continued labor, par- 
ticularly in overhead work. Mowing and tailoring also furnish cases. 
Penetrating wounds occasionally involve it, and falls or blows on the 
back may injure it. It also suffers in association with other nerves as 
a part of spinal atrophies. From the usual traumatic character of the 
disease, men in active middle life are most commonly affected, and on 
the right side, as a rule. 

It occasions weakness in all the movements of the upper extremity 
that depend upon the fixation of the scapula and impairs thoracic in- 








Fig. 102a. — Partial paralysis of the right serratus magnus. 

spiratory expansion on the same side, but causes no absolute motor loss. 
The paralysis of the serratus causes a peculiar and characteristic de- 
formity. Attempts to put the arm forward cause the posterior border 
of the scapula to widely wing out from the chest, so that a deep recess 
is formed behind the shoulder-blade. The upper portion of the bone 
moves outward and the lower angle toward the spine. 

As the nerve is almost purely motor, the only sensory disturbance 
is neuralgic pain in the neck and shoulder in neuritic cases. The prog- 
nosis in injury to the posterior thoracic is comparatively less favorable 
than in other spinal nerves. A serratus paralysis is always of long dura- 
tion and often permanent, even when there is every reason to believe 
that the condition has arisen from a simple pressure neuritis. In cases 




Diagram showing Relations and Disteibuti 



Plate I. 



U rff,,,,, 












Cervical and Brachial Nerves (Flower). 



LESIOXS OF SPECIAL SPIXAL XERYES. 299 

not open to nerve suture Tubby * has suggested and successfully prac- 
tised the ingenious operation of substituting a portion of the pectoralis 
major muscle, which is dissected from its humeral implantation, split 
up, and inserted into the digitation of the serratus. 

The suprascapular nerve arises from the fifth and sixth cervi- 
cal nerves. It may suffer alone in shoulder dislocations. The supra- 
and infraspinati are paralyzed and the scapula becomes subcutaneous 
by their atrophy. The arm can not rotate outward at the shoulder, and 
there is a general lack of balance with weakness in the movements of 
the member. Carrying the hand from within outward, as in writing, is 
rendered especially uncertain and difficult. Anesthesia over the outer 
portion of the scapula and the posterior portion of the deltoid is often 
present. Usually the suprascapular nerve and the circumflex are con- 
jointly injured. 

The circumflex nerve, arising from the fifth, sixth, and seventh 
cervical nerves, descends in the posterior cord of the brachial plexus, 
which it leaves to pass outward under the subscapular muscle, winds 
around the humerus, and is distributed to the teres minor and the del- 
toid. It also supplies the shoulder-joint. It furnishes sensation to the 
skin in a chevron-shaped area over the lower two-thirds of the deltoid. 
From its exposed position on the neck of the humerus and in the axilla 
it is often injured by shoulder dislocations, by arthritis, by crutch pres- 
sure, and by falls or blows on the shoulder. Injury of the circumflex 
causes loss of actio) i on the part of the deltoid, and all attempts fail at 
lateral extension of the arm from the body. The loss of the teres 
minor action is insignificant. 

Owing to the deltoid atrophy 
the acromion is uncovered and the 
shoulder rendered pointed and 
angular. The head of the hum- 
eras can readily be felt from the 
lateral aspect. In some instances 
it drops from its socket, leaving a 
deep furrow under the acromion. 
The nutrition of the joint also 
suffers and arthritis is likely to 
develop, limiting the range of 
joint motion. AVhen the arm is 
passively moved, the scapula does 
not follow it unless joint disease 
is also present. An initial arth- 
ritis, bv involving the articular , Fig. IO3.— Atrophy of the deltoid and deformity 
7 * ~ .01 the shoulder in paralvsis ot the circumflex 

branches, may spread to the cir- nerve. 
cumflex and disable the deltoid. 

Anesthesia in the distribution field of the circumflex over the lower 
two-thirds of the deltoid is usually present. 

The musculospiral nerve is the most frequently injured nerve in the 
arm, perhaps in the body. Arising from the posterior brachial cord, and 
1 ''Br. Med. Jour.," Oct. 9, 1904. 




300 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

arising originally from the fifth, sixth, seventh, and eighth cervical nerves 
or in some cases from the sixth, seventh, and eighth cervical and the first 
dorsal, it winds around the humerus in the musculospiral groove under 
the triceps, where it is subject to muscular compression and external 
violence or pressure. It supplies all the extensors of the elbow, wrist, 
and fingers, both the supinators, and through its radial branch the skin 
on the dorsal surface of the thumb and two radial fingers, and the pos- 
terior radial border of the hand. It also furnishes articular filaments to 
the wrist and carpal joints. By cutaneous branches given off above those 
to the triceps it supplies the skin in an area extending from the wrist in 
a narrow but widening strip up the dorsum of the forearm, and over the 
outer aspect of the arm as high as the insertion of the deltoid. These 
branches, however, are seldom involved in a musculospiral palsy. This 
nerve is injured in a variety of ways, and is especially involved in systemic 
states, such as lead poisoning. In these latter conditions it is interesting 
to note that the supinator longus, w r hich is an active flexor of the elbow, 
does not participate. From its exposed position in the axilla, crutch 
pressure and dislocation of the humerus frequently affect it ; lower 
dow T n on the shaft of the humerus it is injured by fractures, nipped by 
callus, and subject to contusions from blows. Here it is frequently 
compressed injuriously by constricting cords about the arm, sometimes 
by violent action of the triceps, often by pressure during sleep with the 
arm under the body or resting on some hard object, as a chair-back, door- 
step, or bench. Such sleep palsy is sometimes presented after the pro- 





; 

N 

Fig. 104.— Characteristic position of hand in musculospiral palsy. 

longed stupor of drunkenness, surgical anesthesia, or narcotism. Direct 
blows to the arm may also produce musculospiral palsy, and cold is often 
accredited as a cause. 

The motor symptoms of disease of the musculospiral nerve are exten- 
sive, interesting, and characteristic. The elbow and wrist can not be 
extended, and the long extensors of all the digits and the supinators 
of the hand are inactive after a lesion near the armpit. When the 
nerve is affected in the musculospiral groove, the usual location, the 
branches to the triceps escape and elbow extension is preserved. In 
lesions at or below the lower third of the humerus the branch to the 




LESIONS OF SPECIAL SPINAL NERVES. 301 

supinator longus escapes, as it does in systemic affections. The wrist can 
not be extended and wrist drop is produced. The fingers are semiflexed 
and can only be extended by the action of the interossei — which are sup- 
plied by the ulnar — after the first phalanges are passively extended on the 
metacarpals. The thumb lacks extension movements, and those of the 
fingers progressively diminish from the index to the little finger. Fre- 
quently on the back of the carpus 
there develops a synovial tumor 
due to the overcarpal flexion, the 
inadequate support of the extensor 
tendons, and perhaps, in part, to 
the implication of the articular 
branches of the nerve. This con- 
stitutes a dense, painless elevation 
that exaggerates the wrist-drop 
deformity. Unbalanced by the 
extensor paralysis the flexors are 
weakened so that the hand-grasp 
is reduced in strength more than 
half. The muscular wasting 
shows most on the dorsal sur- 
face of the forearm. In those 

Cases that involve the long SUp- Fig. 105.— Dropped wrist from musculospiral palsy, 
1 *i • i j? showiuii' retrocarpal tumor. 

inator a very striking loss of ° p 

contour is presented. The tri- 
ceps may also show diminished proportions. 

Sensory disturbance, in comparison with the extent of the paralysis, 
is very slight. Reference to the diagrams of cutaneous sensation (Figs. 
15 and 16) will give an idea of the average space supplied by the radial 
branch of the musculospiral, but it varies widely in different individuals. 
The close relation with the median and ulnar also obscures the outlines 
of the field of disturbed sensation. One of the usual distributions of 
these nerves is indicated in figure 106. Often only prickling or slight 
numbness is felt in the tips of the thumb and index finger; in other 
cases the anesthesia is complete and sharply limited. In neuritic cases 
there is often complaint of constant pain in the wrist and carpal joints, 
which may be slightly swollen. 

It is particularly in the treatment of dropped wrist that the great 
value of maintaining a proper position of the articulations may be em- 
phasized. The tendency to carry the arm in a flexed attitude and the 
unopposed action of the flexors and pronators of the wrist give the 
carpal articulations a vicious position that is often difficult to overcome, 
and upon convalescence mechanically defeats the returning strength of 
the extensors. The use of a carefully padded and loosely applied ante- 
rior splint to maintain the wrist and fingers in line with the forearm 
hastens recovery in recent and in protracted cases. 

The median nerve, originating in the sixth, seventh, eighth cer- 
vical and the first dorsal nerves, arises in front of the axillary artery by 
roots from the outer and inner cords of the brachial plexus. It follows the 



302 



DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 




Fig. 106. — Distribution of sensory 
nerves on the backs of the fingers. 
r, Musculospiral nerve; u, ulnar 
nerve; m, median nerve (Krause). 



brachial artery to the bend of the elbow, but gives off no branches above 

that joint. It supplies all the flexors on the 
front of the forearm except the flexor carpi 
ulnaris and the ulnar portion of the deep 
flexor of the fingers. It also supplies both 
pronators. In the hand it supplies the 
abductor, opponens, and short flexor of the 
thumb, and the first and second lumbrical 
muscles. These, like the interossei, are 
accessory to the flexors of the fingers for 
motions of flexion at the first joints, but are 
aids to the common extensor for extension 
of the second and third phalanges. The 
cutaneous distribution is subject to the dif- 
ferences pointed out above. In a general 
way we may say that the median supplies the 
radial half of the hand on the palmar side 
and the tips of the index and middle fingers on the dorsal aspects. The 
median is rather rarely injured alone, but commonly suffers with the ulnar, 
or with the ulnar and musculospiral, from injury in or about the axilla. 
It may be divided by stab or bullet wounds in the arm, or fractures and 
wounds in the forearm, especially near the wrist, and by sprains or dis- 
locations of the wrist. It has been torn across in compound Colles' frac- 
tures. Carrying heavy weights or holding objects for a long time in the 
bend of the elbow may set up a median neuritis by compression. 

Motor Symptoms. — Disabling injury of this nerve destroys prona- 
tion, and the thumb can not be rolled into the hand nor opposed to the 
tips of the fingers. The fingers can not be flexed, excepting the ring 
and little fingers, which still act to the ulnar portion of the flexor pro- 
fundus and the interossei. The wrist is flexed weakly to the ulnar side 
by the flexor carpi ulnaris. Through the action of the interossei the 
fingers can still be flexed at the metacarpophalangeal joints. 

The resulting deformity consists in a flattening of the hand through 
loss of the thenar eminence, and the thumb lies in adduction parallel to 
the index in the same plane with the fingers, producing the " ape hand.'' 
This is also the usual deformity in progressive spinal muscular atrophy. 
The little finger retains all its lateral and other motions. The presence of 
the hypothenar eminence and the preservation of the ulnar side of the 
hand are distinctive. The swelling curve on the ulnar side of the fore- 
arm also disappears, and a concave outline may be presented extending 
from the inner condyle to the wrist. From the action of the interossei 
there results a tendency to forward subluxation of the first phalanges of 
the index and middle fingers at the metacarpophalangeal joints. Division 
of the nerve at the Avrist only affects the thenar and first two lumbrical 
muscles and the cutaneous filaments. 

The sensory disturbance is sometimes extremely slight, due to an 
unusually extensive distribution of the ulnar and radial nerves. It is 
most pronounced on the volar surface of the index, but may extend over 
the area shown in figure 107. 

The ulnar nerve originates from the lowest cervical and the first 



LESIONS OF SPECIAL SPINAL NERVES. 



303 



dorsal nerves, and supplies in the forearm the ulnar flexor of the wrist, 
the two inner divisions of the deep flexor of the fingers, and all the small 
muscles of the hand except those innervated by the median — namely, 
the dorsal and palmar interossei, the muscles of the hypothenar emiuence, 
and the third and fourth lumbricales. It also supplies the adductor and 
one-half of the short flexor of the thumb. Its cutaneous branches sup- 
ply the ulnar border of the hand, front and back, including all of the 
little finger, most of the ring finger, and a varying portion of the middle 
finger, largest on its dorsum. 

The ulnar is (1) rarely injured above the elbow, excepting as a 
part of a more general injury to the brachial plexus. (2) At the elbow 





Fig. 107. — Showing areas of sensory loss in injuries of the median nerve (Bowlby). 



its exposed position behind the inner condyle and its superficial course 
through the forearm and at the wrist lay it liable to pressure neuritis 
and injury from wounds of all sorts. Even long-continued extreme 
flexion of the elbow-joint, as in sleep, in one predisposed, may suffice to 
induce a neuritis at this point. Occupations which necessitate continu- 
ous leaning on the elbow are also said to be active causes, but are cer- 
tainly infrequent in this country. (3) Cuts at the wrist with various tools 
or from broken glass frequently divide it. 

Motor Symptoms. — Ulnar paralysis constitutes a serious disability of 
the hand. Flexion at the metacarpophalangeal joints and extension of 
the second and third phalanges, which are dependent on the interossei and 
lumbricales, are lost. The wrist can not be actively flexed to the ulnar 
side, and the thumb is rotated toward the palm by the abductor and 
opponens and can not be adducted. The fingers lose all lateral motion. 

The distortion and deformity that result are pronounced and charac- 
teristic. There is overextension at the metacarpophalangeal joints, 
which makes the head of the metacarpal bones prominent in the hollowed 
palm. The unopposed flexors "claw" the second and third joints, and 
with the strongly-acting common extensor increase the deformity. This 



304 



DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 



is least marked in the index and middle fingers, which do not lose their 
lumbrical muscles. All the interosseous spaces are emptied, and the 
fifth metacarpal is left entirely subcutaneous. In place of the hypothe- 
nar prominence there is a deep hollow. The unaffected muscles of the 
ball of the thumb stand out prominently in contrast with the skeleton- 
like-hand. The loss of sensation is confined to the indicated area of 
cutaneous distribution, but is only complete in the little finger. Figure 
108 shows its distribution and degree. 





Fig. 108. — Showing sensory loss and ordinary position in injuries of the ulnar nerve (Bowlby). 



COMBINED PALSIES OF THE NERVES OF THE ARM. 

It is common for several nerves of the upper extremity to be injured 
at the same time, causing combined palsies presenting symptoms of cor- 
responding extent. The circumflex, suprascapular, and musculocuta- 
neous may be affected simultaneously by disease of the fifth and sixth 
cervical nerves, from which they arise. This is usually caused by 
forcibly dragging the arm downward or upward, lacerating the anterior 
nerve-roots 1 and may occur at birth. In this lesion sensory disturb- 
ance is usually absent. A new growth or injury at a point between 
the scaleni muscles opposite the sixth cervical vertebra may affect both 
spinal nerves. At this point Erb found they could be simultaneously 
stimulated by electricity. The muscles involved are the deltoid, spinati, 
biceps, and brachialis anticus, and the sensory disturbance corresponds 
to the cutaneous distribution of the three nerves in question. Kennedy 2 
reports some such birth accident instances greatly benefited by surgical 
operation. A cicatricial condition was found at Erb's point above the 
clavicle and outside the sternomastoid muscle ; the nerves were resected 
and sutured with comparatively early restoration of motor function. 
This operation tends to become definitely established. For instance j 

1 Huet, Duval, et Guillan, "Rev. Neurolog.." Dec. 15, 1900. 

2 "Br. Med. Jour.," Feb. 7, 1903. 



LESIONS OF SPECIAL SPINAL NERVES. 



305 



Taylor 1 fully reports on the anatomy of the condition with the technique 
of the operation and numerous case records. Operation is recom- 



Wt 




Fig. 109.— Radicular palsy affecting the spinati, deltoid, biceps, and brachialis anticus. 

mended by him during the first or second year. Tubby 2 has 

remedied the defective biceps by utilizing the outer portion of the 

triceps, which is freed from its implantation into 

the olecranon and mattressed into the bicipital 

remnant. 




Fig. 110.— Brachial plexus injury. Area of anesthesia below black line. 

Injuries to the brachial plexus usually involve more than one nerve 
in the arm. Nerve injury arising from dislocations of the humerus 
and from strains on the arm usually implicate several nerves. Thus the 
median, ulnar, and musculospiral may be injured together, or a single 
nerve may suffer. In figure 110 is shown a case suffering from a 

1 "Jour. A. M. A.," Jan. 12, 1907. 2 "Br. Med. Jour.," Oct. 17, 1903. 

20 



306 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

wrench of the arm received in alighting from a moving street-car. 
The ulnar, internal cutaneous, nerve of Wrisberg, and intercosto- 
humeral were simultaneously injured. The anesthetic area could be 
distinctly marked out. A similar combination of nerve-lesions occurs 
in birth-palsies from pulling on the arm or using a hook over the neck or 
in the axilla. Figure 111 shows the deformity in such a case : in a breech 
presentation attempts were made to draw the arm down from the side of 
the head and resulted in injury to the median, ulnar, and nmsculospiral. 
Fractures of the humerus may involve the ulnar with the musculo- 
spiral. Fractures in the forearm may injure the radial and ulnar nerves, 
which, also, may be simultaneously implicated in wounds at the wrist. 

In an ascending neuritis other associated nerves are likely to be 
affected if the inflammation reaches the plexus (neuritis migrans). This 
most frequently results from infected wounds. A neuritis traveling up 
the median will first invade the ulnar and musculocutaneous, and then 
the other nerves arising from the brachial plexus. The order in which 
the symptoms arise is the key to diagnosis. 

Disease of the cervical vertebrae, as Pott's disease ; of the meninges, as 

cervical pachymen- 
ingitis ; or disease 
of the cord, as 
syringomyelia, may 
involve the brachial 
nerves in varying 
groups. 

Neuritis of the 
brachial plexus is 
a rather common 
condition that is 
usually mistaken for 
a neuralgia, angina 
pectoris, or a rheu- 
---— — ^_ — — — -^ """ matic trouble in 

i J the shoulder and 

Fig. 111.— Brachial palsy from birth-injury, due to traction in axilla. arm. According to 

Gowers, who first 
carefully described it, brachial plexus neuritis is analogous to sciatic 
neuritis in the lower extremity. 

Causes. — This disease of the brachial plexus is encountered mainly 
after middle life, and especially in rheumatic and gouty subjects. In 
the majority of cases there is a history of attacks of lumbago or sciatica 
and a strongly marked lithemic heredity. Women suffer more frequently 
than men. 

Symptoms. — Pain is the first and constant complaint. It is often 
of rather sudden onset and is likely to come in paroxysms, especially at 
night, becoming more continuous, but still with exacerbations. Motion 
that stretches the plexus, such as elevating the arm, is sure to provoke it, 
and any considerable use of the member is inhibited by the pain to which 
it gives rise. The pain may begin first in the region of the plexus, in the 




■ 



LESIONS OF SPECIAL SPINAL NERVES. 



307 



clavicular hollows, or under the scapula, but soon involves the entire arm, 
runs up into the neck, and frequently affects the side of the chest. 

Upon manipulation one or all of the nerves in the arm will be found 
tender to the touch, and this tenderness can be traced through the axilla, 
under the clavicle, and into the scaleni muscles at the side of the neck. 
There is often tenderness over the scapula in the distribution of the 
suprascapular nerve. The skin over the arm is usually hypersensitive, 
and the constant dragging ache in the shoulder and arm is almost unen- 
durable. The patient is constantly trying to find an easier position for 
the extremity, but without success. The tender muscles become flabby and 
wasted, and sometimes show slight 
degenerative reaction to electricity 
in certain groups. Dermal, epithelial, 
and vasomotor disturbances are not 
infrequent. The reflexes are dim- 
inished, rarely exaggerated. 

Diagnosis. — The diagnosis rests 
on the continuous character of the 
pain, the tenderness of nerve-trunks, 
plexus, and roots, and the evidences 
of the neuritic process in the dermal 
changes, the vasomotor failure and 
the tendency to, if not the presence 
of, muscular atrophy. The presence 
of joint disease in old, gouty, and 
rheumatic patients may mislead as to 
the order of events, for the joint dis- 
turbance may be induced by the neu- 
ritis, or vice versa. The history must 
determine the point. Inflammation 
or injury of the subacromial bursa 
may easily be mistaken for a neuritis. 
It is marked by a distinctly painful 
point just below the tip of the acro- 
mion and by the pain caused when 
the elbow is abducted more than 10 or 
15 degrees from the side of the body. 

Prognosis. — Brachial plexus neu- 
ritis is always a protracted malady, 
requiring from three to eighteen 
months, or more. In old arthritic 
individuals it is especially inveterate, 
but usually terminates in recovery, 
and some slight disability in the way of pain or weakness is likely to 
persist permanently. The long maintenance of flexed positions, with 
the double tendency to joint disturbance furnished by the rheumatic 
element and the nerve-lesion, frequently result in a limitation of the 
range of motion at the shoulder and elbow. The wrist and smaller joints 
may also be affected and the use of the hand considerably impaired. 

Treatment. — The treatment is that for neuritis with especial atten- 




eft side with wasting of arm and forearm. 



Relapses are likely to take place, 



308 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

tion to the gouty state. Repeated counterirritation on the side of the 
neck, in the clavicular fossae, and on the inner aspect of the arm with 
blisters or the Paquelin cautery may be used from the first. The arm 
should be immobilized, except for the mildest daily passive movements 
slight massage, and electricity when the tenderness and pain permit. 

NERVES OF THE TRUNK. 
The individual nerves supplied to the trunk by the thoracic and two 
upper lumbar pairs are rarely singly involved. A vertebral lesion or a 
wound may so affect them, but the motor loss is hardly appreciable un- 
less several suffer simultaneously. The neuritic pain arising from Pott's 
disease and the girdling sensation in this malady and in tabes dorsalis 
have great value from a diagnostic standpoint. There is also some truth 
in the lay apprehension that herpes zoster may be fatal if it completely 
girdles the trunk, as in such instances it almost always arises from some 
implication of the nerve-roots by spondylitis, malignant growths, or 
other serious local mischief. Though irritation of a nerve may cause 
a localized herpetic eruption, in true zoster the lesion is an inflammatory 
disturbance of the posterior root ganglia (see page 337). 

THE NERVES OF THE LOWER EXTREMITY. 

The nerves of the lower extremity are much less frequently diseased 
than those of the arm, but are subject to special accidents by pressure 
on the lumbar and sacral plexuses within the body, as from parturition 
and abdominal and pelvic growths. Psoas abscess and inflammations 
of the pelvic viscera may also invade these plexuses. 

The anterior crural nerve may be affected (1) within the abdo- 
men, when the iliacus is affected and flexion of the thigh on the body 
is weakened, or (2) below Poupart's ligament. After a paralyzing lesion 
the extensors of the knee are inactive and wasted and the knee-jerk is 
abolished. Difficulty is experienced in advancing the foot, especially 
in mounting stairs. Anesthesia extends from the groin to the inner side 
of the foot, involving the entire extremity except the buttock and a 
narrow strip down the back of the thigh, which below the knee spreads 
over the outer side of the calf and embraces the foot excepting on the 
inner margin (see diagrams, pp. 52 and 53). This nerve was observed 
to be affected seventeen times in 1000 patients in the lying-in hospital 
of Copenhagen, in all subsequent to parturition. 1 As shown by Byrnes, 2 
this nerve is affected singly but rarely by neuritis or pressure injury. 
Gout, rheumatism, diabetes, infectious diseases, toxic and septic con- 
ditions, obstetric and surgical procedures, exposure, and occupational 
traumata are among the causes. Direct injury, inflammatory, extension 
from appendicitis, and pelvic disorders have also been reported. 

The external cutaneous branch of the anterior crural supplying 
the outer side of the thigh seems especially subject to sensory disturb- 
ances. In gout, alcoholism, tobacco excesses, and sometimes as a linger- 
ing feature in multiple neuritis this area is sometimes exquisitely hy- 
peresthetic, so that the patient finds it inconvenient even to allow the 
weight of the trousers upon the skin, or is conscious of an acute ting- 

1 "Centralbl. f. Gynak.," No. 25, 1901. 

2 "Jour. Nervous and Mental Dis.," Dec, 1913. 




^ 



■:.--,. 




Diagram showing Kelations and Distrib 



Plate II 







)F Lumbar and Sacral Nerves (Flower). 



LESIONS OF SPECIAL SPINAL NERVES. 



309 



ling when he passes his hand over the thigh, or complains of various 
persistent paresthetic sensory disturbances. The condition is called 
meralgia paresthetica and may be due to defective return circulation 
associated with varicose veins and hemorrhoids. It is usually a neuritis 
and the nerve has been found thickened at the point where it crosses 
the pelvic brim. 

The obturator nerve has the same origin as the anterior crural and 
supplies mainly the adductors of the thigh and the hip- and knee-joints. 
Its paralysis interferes with movements that require approximation of 
the knees and impairs outward rotation of the thigh through weakness 
of the pectineus and external obturator. There is wasting on the inner 
aspect of the thigh. The sensory disturbance is confined to the hip- and 
knee-joints, which may also display trophic disturbance. The knee pain 
in morbus coxae is a familiar complaint due to irritation of this nerve. 

The superior gluteal nerve supplies the gluteus medius and mini- 
mus and the tensor vagina? femoris. Its injury interferes with ab- 
duction, outward rotation, and circumduction of the thigh. 

The great scia.tic nerve is diseased singly more frequently than any 
other nerve in the lower ex- 
tremity. Its size and exposed 
position within the pelvis, at the 
sciatic notch, and behind the neck 
of the femur, and the exposed 
position of its brandies, notably 
the external popliteal as it turns 
around the fibula just below the 
knee and the plantar branches in 
the sole of the foot, lay it especi- 
ally liable to accidents. It sup- 
plies the flexors of the knee, 
which also assist in maintaining 
extension of the body on the hip, 
and all the muscles below the 
knee. In spite of its size and 
extensive muscular distribution, 
paralysis of the sciatic nerve is 
not so disabling as that of the 
anterior crural. The hip-joint 
can be fairly controlled by the 
muscles that escape, and the knee 
is kept in extension through the 
anterior crural. The whole ex- 
tremity is then thrown forward 
en masse and used as a peg-leg, 
as in the hemiplegic gait (see 
p. 216), but without rigidity. 

The anesthesia that results 
from palsy of the great sciatic 

occupies a narrow strip from the gluteal fold to the ham, where it spreads, 
embracing the outer side of the leg as far forward as the tibial crest, and 




Fig. 113.— Paralysis of auterior crural ; wasting of 
right thigh. 



310 DISEASES OF SPIXAL MENINGES AND SPINAL NERVES. 

all the ankle and foot except on the inner side. The wasting is marked 
on the back of the thigh and below the knee; the limb may be reduced 
to the last degree. Perforating ulcers on the sole of the foot, par- 
ticularly at the ball of the great toe, are likely to develop. 

The external division of the sciatic, the external 'popliteal or peroneal 
nerve, occupies an exposed position (1) in the ham and (2) below the 
knee on the outside of the neck of the fibula. It supplies the extensors of 
the foot, the long extensors of the toes and the peronei, and is analogous to 
the lower portion of the musculospiral in the arm. Its paralysis causes 
foot-drop and toe-drop. The muscular fullness on the anterior and outer 
aspect of the leg is lost; the uncovered crest of the tibia is extremely prom- 
inent. A tendency to equinovarus is produced that is often rendered a 
permanent deformity by contracture in the calf-muscles. The outer 
half of the front of the leg and the dorsum of the foot are anesthetic. 

The inner division of the sciatic, the internal popliteal, is analogous 
to the median and ulnar in the upper extremity. It supplies all the 
calf-muscles, the long flexors of the toes, and all the small muscles of 
the foot except the short extensor of the toes. It divides into the in- 
ternal and external plantar nerves, which are sometimes singly diseased. 
When the internal plantar, which is analogous to the median, is alone 
divided, we have paralysis of the short flexor of the toes, the plantar 
muscles of the great toe except the adductor, and the two inner lum- 
bricales. The big toe becomes overextended at the first joint and flexed 
at the second, producing the deformity called hammer-toe. There is 
anesthesia on the inner portion of the plantar surface, embracing also 
the plantar surface of three and a half toes. 

When the external plantar, the analogue of the ulnar, is divided, the mus- 
cles of the little toe, the two outer lumbricales, the adductor hallucis, and all 
the interossei are paralyzed. All the toes assume the hammer-toe deformity, 
and the use of the foot is much weakened. Anesthesia is produced on the 
outer half of the sole and on the plantar surface of the little and one-half 
of the next toe. The dorsal surface of the foot and toes is supplied by 
the musculocutaneous and anterior tibial nerves from the peroneal. 

When the internal popliteal is divided in the ham, in addition to 
the disability due to paralysis of both plantar nerves we have a loss of 
inward rotation of the flexed leg, due to paralysis of the popliteus muscle, 
and loss of power of extending the foot on the leg. By the overaction 
of the anterior leg-muscles talipes calcaneus is produced. The arch of 
the foot at the same time becomes exaggerated ; the toes are extended at 
the first and flexed at the other joints, producing the analogue of the 
combined ulnar and median deformities in the hand. 

Metatarsalgia, or Morton's disease, probably consists of a pressure neu- 
ritis or neuralgia of some, usually one, of the digital branches of the 
plantar nerves between the heads of the metatarsal bones. It com- 
monly arises from the use of too narrow boots, and can be remedied in 
some cases by a shoe of proper width snugly embracing the arch of the 
foot. In the sole a depression is fashioned to relieve pressure on the 
particular painful point. Excision of the metacarpal head or neu- 
rectomy have both been employed successfully in severe cases. 

Sciatic Neuritis. — Neuritic and neuralgic conditions have been so 



LESIONS OF SPECIAL SPINAL NERVES. 31 1 

confused under the term sciatica that it is best avoided. Persistent pain 
confined to the region of the great sciatic nerve and its distribution, with 
tenderness in the nerve- trunk, is almost always due to neuritis. Sciatic 
neuralgia, on the other hand, is a rare affection. Inflammation of the 
sciaticnerve, from its clinical importance, demands separate consideration. 

Causes.- — The causes of sciatic neuritis are those of neuritis else- 
where, and may be divided into those of a general and those of a local 
sort. In the first group we may name adult age, as sciatic neuritis is 
comparatively rare before twenty-one. Males are much more commonly 
affected than females, in the proportion of 8 to 1, according to Gibson. 1 
Gouty, rheumatic, and neurotic individuals are especially liable to develop 
it. Among systemic poisons that favor its occurrence may be mentioned 
lead, diabetes, syphilis, typhoid fever, malaria, and grip. Pelvic dis- 
ease and pelvic hyperemias seem also active in causing sciatic neuritis, 
often acting also as local causes by transmitting pressure or inflammation 
to the sacral plexus. It is most frequent in wet and cold seasons and 
among those whose occupations expose them to wet weather or extreme 
changes of temperature, such as stokers, puddlers, and laundresses. It 
may follow operations done in the lithotomy position. 

Among the numerous local causes cold is usually considered most 
important. Sitting on damp ground or on cold stones, standing in water, 
or wearing wet clothing or shoes. Compression of the nerve in sitting 
or by vigorous action of the leg-flexors and rarely contusions from blows 
below the sciatic notch may induce it. Bony thickening at the notch and 
syphilitic deposits at this site have occasioned a sciatic neuritis. In 
quite a proportion of cases there is an antecedent lumbago. The down- 
ward extension of the process in the muscles and fascia involves the 
sciatic nerve at the notch. All sorts of pelvic tumors and even constipa- 
tion are capable of exercising such pressure on the sacral plexus that a 
sciatic neuritis follows. The nerve is sometimes injured in this position 
by the obstetrical forceps or through compression by the gravid uterus 
and fetal head. Spinal disease and new growths within the spinal canal 
may give rise to neuritis by affecting the nerve-roots in the cauda equina 
or at the vertebral foramina. Excessive fatigue of the legs, as in the use 
of the sewing-machine, and the pressure of varices in the extremity or 
in the pelvis or about the nerve-trunk may occasion it. William Bruce 3 
takes the extreme ground that sciatica in practically every instance 
is due to hip-joint disease, an expression of some sort of arthritis, and 
more particularly of the upper and back portion of the capsule or ace- 
tabulum. The condition of the corresponding hip- joint should be exam- 
ined in every case, but sciatica is no part of severe or destructive coxitis. 

Morbid Anatomy . — From rare autopsies and occasional operations 
the condition in the nerve is found to be a perineuritis, affecting 
also the adventitia. Secondarily the nerve-fibrils suffer. There is 
often an increased vascularity and redness of the nerve, and varicose 
dilatations in and about the nerve have been observed by some. The 
nerve is usually edematous and tumefied. In a word, we have to 
deal with an interstitial neuritis. Hunt 3 describes a perineural jelly- 

1 "Lancet," London, 1893, No. 3633. 2 "Sciatica," Wood & Co., N. Y., 1913. 

3 "Am. Med.," April 15, 1905. 



312 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

like, quite structureless deposit in the nerve sheath unaccompanied by 
inflammatory changes and probably of gouty or rheumatic relationship. 
It is usually most marked at the sciatic notch and in the middle of the 
thigh, but may be more widely diffused. A similar condition is some- 
times found in the branches, particularly the external popliteal. 

Symptoms. — The primal symptoms of sciatic neuritis are pain and 
tenderness. While both have a tendency to extend throughout the 
sciatic territory, at first, and often during the entire case, they are con- 
fined to the crural portion of the nerve and are most intense below the 
gluteal fold and in the upper half of the thigh directly in and over the 
nerve-trunk. The patient will often trace with his finger the seat of 
pain in a line that anatomically corresponds to the nerve itself. Below 
the knee the pain follows by preference the external popliteal nerve. 
The pain varies in degree, but is persistent in character, and even when 
slight is extremely wearing by its continuance. It is notably subject to 
exacerbations, which are quite likely to occur at night and seriously in- 
terfere with sleeping. Walking or any vigorous use of the limb is 
likely to increase the pain at once. Even after many hours of freedom 
from it, the pain may sometimes be promptly reestablished by taking a 
few steps. In bed the patient holds the limb by preference in a semi- 
flexed position at the hip and knee with the ankle extended. This 
obviates compression of the nerve by the muscles and avoids stretching 
the nerve by extension. If the nerve is stretched over the femoral 
neck, by extending the knee and flexing the thigh on the pelvis, pain is at 
once produced. These conditions give rise to a characteristic attitude 
and gait The patient holds the knee semiflexed and inclines the body 
to the opposite side, throwing into prominence the hip on the side of the 
sciatic neuritis. This tends to keep the weight on the sound limb, but 
its long continuance may develop a well-marked scoliosis with the lum- 
bar spine convex to the neuritis and a compensatory dorsal curvature 
convex to the sound side. After recovery from the neuritis this scicdic 
scoliosis usually disappears. The scoliosis occurs in the opposite sense in 
cases marked by spasms in the affected leg and thigh, which are due to 
involvement of the sacral plexus or the lumbar cord, and manifest espe- 
cially in the distribution of the anterior crural nerve. The hip on the side 
of the neuritis is then approximated to the lower ribs, the opposite one 
made prominent ; the lumbar curve is concave, the dorsal curve convex, 
on the side of the disease. This homologous sciatica scoliosis is likely to be 
permanent inasmuch as the condition upon which it develops is a chronic 
one and contractures develop to fix the deformity. In walking there is 
an evident intention to use the diseased limb as little as possible in order 
to avoid tension and muscular compression of the inflamed nerve. 

Pressure made with the fingers along the trunk of the nerve and its 
branches develops tenderness, which is greatest in certain regions. 
These correspond to the tender points of Valleix. The most constant 
are the following : The ghdecd point over the sciatic notch, the 
trochanteric point above the trochanter major, a tract corresponding 
to the nerve-trunk on the posterior aspect of the thigh, a popliteal point 
in the ham at the division of the nerve, a jibidar "point where the exter- 
nal popliteal is superficial to the neck of the fibula, and a point on the dor- 



LESIOXS OF SPECIAL SPIXAL XERVES. 



313 



sum of the foot. Frequently we find lumbar points just above the sacrum, 
an iliac point at the middle of the iliac crest, a patellar point over the 
knee-cap, points in the calf, points behind the malleoli, and plantar points 
in the sole of the foot. Gara x and Rainist 2 insist that tenderness is 
always to be elicited by pressure on or at the side of the fifth lumbar 
spinous process. 

It is at these points that the patient complains of the paroxysms oj 
pain that commonly mark the course of the disease. They are often of 
a lancinating, boring, tearing, burning character that racks the patient 
and exceeds his power of description and endurance. They are usually 
provoked by use of the member, by an exposure to cold, or by some manip- 
ulation of the parts, but may come on spontaneously and even periodi- 
cally, as in malaria. They often follow sleep, probably from pressure 
or a continued cramped position. 

Cutaneous sensibility is often modified. Hyperesthesia in the sciatic 
area is the rule at first, but in prolonged or severe cases gives place to 
anesthesia. Often the hypersensory disturbance is confined to small 
areas which correspond fairly well to the painful points previously indi- 
cated. Various paresthesias are encountered, such as a feeling of cold, 
heat, prickling, fullness, formication, 
etc. 

Motor disturbances are less constant 
and present much variation. They 
usually only appear in the graver 
cases. Sometimes the member is 
shaken in a spasmodic manner during 
the painful paroxysms, and painful 
cramps in the calf-muscles may ag- 
gravate the patient's suffering. Re- 
flexes: The knee-jerk is rarely ex- 
aggerated, usually it is diminished, 
and the Achilles tendon reflex is al- 
most always greatly reduced or absent. 
Gibson 3 notes that the cremasteric 
reflex is usually exaggerated and the 
plantar may be increased, but the toe- 
sign of Babiuski is never present. If 
the muscles waste, fibrillar twitching is 
frequently observed, and there is pare- 
sis or paralysis. In the rare spasmodic 
cases already mentioned, in which the 
plexus or cord is involved, the entire 
limb may be drawn up in a painful and 
protracted spasm upon the slightest 
cutaneous irritation, even by a breath 
of air or the contact of clothing. 

Involvement of the vasomotor and 
trophic functions of the nerve in severe and protracted cases renders the 

1 "Wiener med. Wochensch.," 1907, Xo. 23. 2 "Neurolog. Centralblatt," 1909, Xo. 20- 
3 "Edin. Med. Jour.," Xo. 9, 1901. 





Fig. 114. — Sciatica of long duration on 
astiug of buttock and leg, some 
contracture -n-ith tendency to stand on toe, 
elevation of hip, and scoliosis. 



right side ; 



314 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

limb livid in color, cold to the touch, with a temperature reduced several 
degrees. The perspiration is usually reduced, but may be increased, and 
the dermal structures frequently suffer, as in neuritis elsewhere. Scaliness, 
herpetiform eruptions, erythema, and acne sometimes appear, and perfo- 
rating ulcer has been encountered. The muscles waste and show the 
reaction of degeneration to electricity. The wasting is most noticeable 
in the leg and buttock. The enlarged nerve may sometimes be felt. 
An increase of cutaneous fat may mask the muscular wasting. 

A double sciatic neuritis is almost invariably due to spinal disease or 
pelvic disorder, to the suspicion of which it should always give rise. 

Diagnosis: — The diagnosis of a sciatic neuritis is not ordinarily diffi- 
cult. It is based on persistent pain and upon the presence of the ana- 
tomically located tenderness. Neuralgia gives rise to fleeting pain 
without tenderness or with relatively very slight tenderness, but early 
in neuritis this combination may also obtain. Disease of the hip-joint 
is sometimes mistaken for sciatic neuritis. Here joint tenderness and 
fixation and the location of the pain, which does not correspond to the 
sciatic but to the obturator nerve, serve to differentiate the articular 
disease. Hysteria sometimes mimics sciatic neuritis. The onset of 
the disorder under emotional stress, the absence of trophic disturbance, 
and the presence of contractures and other stigmata of the neurosis dis- 
tinguish it. When the neuritis has resulted in wasted muscles, cutane- 
ous eruptions, etc., it can hardly fail of recognition. 

More difficult questions are those of the causation and location of the 
primal inflammation. In every instance a thorough investigation should 
be made of the pelvic organs and the spinal functions. If the neuritis 
is bilateral, the disease is almost surely above the sciatic notch. In 
tabes sciatic pains are very frequent, but their lancinating character 
and appearance in storms, with other symptoms and signs of the 
disease, should lead to their proper classification. By the injection 
of cocain into or close to the nerve at the sciatic notch the neuritic 
pain is inhibited, unless the trouble is higher up, and this measure, there- 
fore, helps to locate it within or outside the pelvis. A history of syph- 
ilis, malaria, or climatic exposure sometimes tells the whole story. 

Prognosis. — A pure sciatic neuritis is of good ultimate prognosis. 
If, however, it be due to pelvic or spinal disease, the outlook is modi- 
fied for the worse by such conditions and in proportion to their gravity. 
As in any other neuritis, the probable duration must be estimated from 
the degree of severity of the neuritic process. The manageability of 
the patient has much to do with the prospects of a given case, as a 
great deal depends upon rest, and preferably rest in bed. Usually the 
disease lasts several months, and under conditions of use and irritation 
may extend over years or present numerous relapses. If nerve degen- 
eration and muscular atrophy develop, from six to nine months will be 
required for recovery, though the pain may subside much sooner. 

Treatment. — The general plan of treatment of a sciatic neuritis 
corresponds to that of any ordinary neuritis (p. 292), but certain local 
conditions require special attention. First of all and most important 
in the early stage is complete rest of the limb by absolute rest 



LESIOXS OF SPECIAL SPIXAL XERVES. 315 

in bed. This can be rendered the more effective by the use of 
a long, well-padded splint, extending from the armpit to below 
the foot, where a cross-piece on the surface of the bed serves to 
maintain a proper position of the whole. To this splint the limb 
should be lightly secured in a comfortable position, slightly flexed 
at the hip and knee. The upper end of the splint is secured to 
the chest by webbing bands or a binder. Care must be taken not to 
constrict the limb at any point. Gouty, rheumatic, and other favor- 
ing conditions require appropriate attention, and, of course, pelvic 
and intestinal trouble must be properly treated. From the very first, 
counterirritation over the nerve-trunk should be employed. This may be 
in the form of sinapisms, small blisters, or preferably by the Paquelin 
cautery. Continuous use of hot poultices or the ice-bag is to be advised. 

Internal medication is practically useless, though some favor mercury, 
others salicylates, and lately nitroglycerin, in y^-grain doses every two 
or three hours, has been lauded. In the writer's experience it has had no 
value. An exception to the above statement is furnished by recent 
and acute cases. In such 30 grains of aspirin or similar salicylate, with 
an equal amount of sodium bicarbonate to protect the stomach every 
hour for six doses will often work wonders. During this intensive medi- 
cation the patient must be kept absolutely in bed and under intelligent, 
watchful supervision. A little digitalis, strychnin, or caffein may be 
added to support the heart. If good effects are secured, the salicylate 
in smaller doses at longer intervals must be kept up for several days. 

Acupuncture over the course of the nerve serves the same purpose 
as any other form of counterirritation, and the same is true of injections 
of ether and other fluids. Gibson 1 advises puncturing the nerve- 
trunk itself with a good-sized needle in about five places, and reports, 
in 100 consecutive cases, 56 cured, 32 much improved, 10 improved, 
and 2 unimproved. The purpose of the nerve-puncture is to relieve 
the supposed edema within the sheath. The usefulness of the meas- 
ure is, therefore, limited to early cases. For the same reason the needle 
should be used at the point of involvement, which is usually opposite the glu- 
teal fold. When the nerve is thus pierced, a pain darts down its course. 
The needle is to be inserted at intervals of about an inch in the course 
of the nerve in the thigh, five times at a sitting, and repeated after two 
or three days. A somewhat similar treatment consists in puncturing 
the nerve near the sciatic notch with a hollow needle and injecting sev- 
eral cubic centimeters of a sterile normal salt solution. Xegro 2 reports 
113 rebellious cases in which vigorous pressure over the nerve at the 
most painful part resulted in recovery. He places the patient on his 
face, and, with all his force, presses both thumbs upon the nerve, rolling 
it from side to side for fifteen seconds. This is repeated after twenty- 
minutes, aud it is then much less painful than at first. The patient is 
relieved of pain for several hours and is enabled to walk. It is rec- 
ommended that this manipulation be done about six times at two-hour 
intervals every second or third day. This procedure would seem better 
calculated to cause than to cure a neuritis, but is certainly valuable. 

1 "Lancet," London, 1893, No. 3633. 

2 "Bulletin Med. de Paris," Jan. 22, 1896. 



316 DISEASES OF SPIXAL MEXINGES AND SPINAL XERVES. 

Vigorous massage of the nerve in early eases has always seemed, in the 
writer's experience, to increase the pain and intensify the trouble, but in 
late cases is of great benefit, particularly in building up the wasted mus- 
cles. Electricity is also extensively used by some. "When the inflam- 
mation is recent and the pain severe, a majority favor a broad, positive 
sponge-electrode over the nerve, with sufficient unbroken current to red- 
den the skin. In old cases the vigorous faradization of the thigh- and leg- 
muscles, though painful, sometimes seems to be of benefit, perhaps by the 
mechanical muscular pressure thus induced. High-frequency currents 
sometimes produce im mediate and remarkably favorable results. So also do 
static sparks. Stretching the sciatic over the neck of the femur by forcibly 
flexing the hip-joint with the knee fully extended is also useful in late stages. 

In most cases sedatives are required. Morphin is the only certain 
anodyne, but its disadvantages in the face of a protracted disease should 
postpone its use to the last moment. The coal-tar derivatives have some 
effect, and cocain, y 1 -^ of a grain injected near the nerve, acts very well. 
The best results will probably follow complete rest and vigorous counter- 
irritation in the early stage ; active massage, cutaneous stimulation, and 
free use of the limb in protracted cases. 

Various springs and watering places have gained a reputation in the 
treatment of sciatic neuritis. All furnish hot baths and much rubbing 
or rude massage. The enforced idleness, abundant excretions due to 
drinking the water, frequent baths, and manipulations are the factors of 
their success. In early cases such a course is often clearly detrimental. 



MULTIPLE NEURITIS. 317 



CHAPTER IV. 
MULTIPLE NEURITIS. 



Under the terms multiple neuritis, multiple peripheral neuritis, poly- 
neuritis, beri-beri, kakke, etc., are embraced a number of conditions 
which have groups of symptoms mainly referable to disturbed functions 
of the peripheral nerves. The old-time distinction between central and 
peripheral organs and the clinical features of these cases directed atten- 
tion mainly to the nerve-trunks and endings. In view of our present 
knowledge of the neuron unit, supported by numerous observations 
showing spinal nuclear involvement and even cerebral cortical disturb- 
ance in multiple neuritis, the term peripheral must be dropped. By 
multiple neuritis or polyneuritis is here meant a malady in which the 
anatomical lesions open to our present means of investigation are usually 
more pronounced in the nerves than in the central organs, and commonly 
consist of degeneration of the axis-cylinder process. Cases in which 
no histological change is found can not always be excluded, as many of 
the numerous poisons giving rise to the disease may, so far as we can 
detect, sometimes produce dynamic modifications alone. It is also 
allowable to suppose that the early effects of such poisons are perturba- 
tive of nerve-cell activity, to which the degeneration in the distant axis- 
cylinder process is secondary, and that if the poisoning be slight in 
degree, or the investigation be made before the secondary results are 
developed, no change whatever will be presented. Finer methods, how- 
ever, are daily displacing post-mortem appearances which were formerly 
considered normal, and the dynamic cases are being steadily brought 
within the domain of the morphologically abnormal. It is likely that 
polyneuritis were better classed as a general disease of the nervous 
system. The preponderance of neuritic conditions has dictated its de- 
scription in this connection. 

Etiology. — Polyneuritis is the result of a systemic poisoning or of 
conditions which entail depraved nutrition, or of both. The toxic sub- 
stances which are capable of producing a multiple neuritis are most com- 
monly alcohol and lead ; less frequently arsenic, mercury, silver, phos- 
phorus, sulphid of carbon, oxid of carbon, and ergot. In Manchester, 
England, an epidemic of multiple neuritis was traced to arsenic in the 
beerr^Certain autotoxic substances may be developed that have the same 
pathogenic power, as in diabetes, nephritis, and intestinal disturbance. 

The infections furnish another group of causative agents. Most of 
the infectious fevers — typhoid, typhus, the exanthemata, erysipelas, puer- 
peral infection, acute rheumatism, influenza, and, above all, diphtheria — 
are occasionally followed by a multiple neuritis, which usually appears 
during convalescence. Even whooping-cough has been complicated by 
multiple neuritis. 2 In rare instances the neuritic disturbance appears 

1 J. S. Bury, "Br. Med. Jour.," Dec. 1, 1900. 

2 Eshner, "Jour. Am. Med. Assoc./' Jan. 10, 1903. 



318 DISEASES OF SPINAL MEXIXGES AND SPINAL NERVES. 

early in these infectious diseases, and again rarely it may follow them 
after a considerable period of time, even after several months have inter- 
vened. The related toxins are assumed to be the determining agents. 

Syphilis and tuberculosis have both been cited as causal of poly- 
neuritis. Undoubtedly they both predispose to it by the systemic de- 
pression they occasion, and both are capable of producing a local neuritis 
by their specific proliferations. The anesthetic form of leprosy is fre- 
quently marked by a polyneuritis which is actually a peripheral disease 
and due to the invasion of the nerve-trunks by the bacillus lepra?. 
Malaria can undoubtedly produce it. Eisenlohr, in Homburg, and 
Graeme Hammond, in Connecticut, have reported small epidemics of the 
disease, which also in the form of beri-beri is common in certain parts of 
Asia, South America, and on shipboard during long voyages. 

Cachexias of all sorts, but especially those associated with cancer, 
are likely to develop polyneuritis ; usually, however, combined with 
changes in the spinal cord. Old age, and especially old age marked 
by extreme arteriosclerosis and atheroma, may be the occasion of the 
disease by failure of nutrition both in the trophic spinal apparatus 
and in the peripheral nerve-trunks. Multiple neuritis occurs infre- 
quently before adult age. In children it is usually due to infection, 
especially diphtheria, measles, and influenza. Much more rarely it is 
caused in childhood by lead or arsenic. Arsenic has caused poly- 
neuritis in some cases of chorea where it has been too freely used. 
After adult age is reached all forms are comparatively common. 
Alcoholic polyneuritis is most frequent between thirty and forty. The 
senile and atheromatous forms appear only after sixty. Women fur- 
nish the greater proportion of alcoholic cases ; men, of the rheumatic and 
toxemic variety. Occupation plays a large part. Painters, plumbers, 
type-setters, rubber-workers, match-factory employees and employees in 
white-lead factories, and lead-miners are especially exposed. Various 
other pursuits requiring the use of lead, arsenic, and mercury, or the 
handling of spirituous liquors, the last by indulgence, furnish many 
cases. Very often more than one cause is operative, as when tubercu- 
losis leads to constant alcoholic stimulation, or the onset of physical or 
mental depression in an alcoholic precipitates the attack of polyneuritis. 

Morbid Anatomy. — Lesions in the Nerves. — In the very great 
majority of cases the condition found in the nerve-trunk is one of degen- 
eration comparable to that caused by traumatism, with the difference that 
in polyneuritis the nerves show many axis-cylinders in a comparatively 
normal condition. Indeed, all grades of Wallerian degeneration may be 
encountered in a single nerve, the fibers being differently affected by 
the toxic agent. It is also evident that the intensity of the toxic pro- 
cess and the duration of the disease will produce corresponding modifi- 
cations in the nutrition of the axis-cylinder. It is possible that event- 
ually we will be able to distinguish a variation in the degeneration 
produced by the various provocative agents, but at present they escape 
detection. The degeneration following lead-poisoning is apparently 
identical with that caused by toxins. The intensity of the neuritis 
generally decreases from the periphery toward the centers. Hyperemia 



MULTIPLE NEURITIS. 319 

of the endo- and perineurium is frequently observable. In addition to 
the axis-cylinder changes in some cases, usually those of long standing, 
there is an increase in the adventitia. A considerable thickening of the 
nerve-trunk results. This fibrous proliferation may even be excessive and 
at exposed points sometimes produces nodular enlargements. Syphilitic, 
leprous, and tubercular changes incident to these various diseases are also 
encountered. In the leprous form the nerve may also contain the char- 
acteristic bacilli. Ceni, 1 Crocq, 2 and others, by inoculation experiments 
in lower animals, have produced the same changes in the nerves and in 
the spinal cord as are found in human subjects, but not in the brain. 

Lesions of the Spinal Cord. — In a considerable and constantly grow- 
ing number of cases the cellular parts and even the conduction tracts of 
the spinal cord have shown involvement. Oertel, Dejerine, and Pernice 
have described lesions of the anterior horns in diphtheric neuritis. Many, 
among them Finlay, Achard, Schaeffer, Larkin and Jelliffe, 3 and Clarke, 4 
have noted the same thing in alcoholic neuritis. Others again, as Thiersch 
and Rosenbach, recognize a simple atrophy of the cornual cells in lead- 
palsy. The cells of Clarke's column and the fibers of the posterior and 
cerebellar tracts have presented diffuse lesions of an inflammatory and 
degenerative nature. This observation has been confirmed by Herzog. 5 
Henschen 6 records a case of typical diphtheric polyneuritis followed by 
acute disseminate sclerosis. The spinal cellular changes consist either 
of a changed crenelated form with vacuolation, or of changes of an in- 
flammatory character, sometimes with hemorrhages. The lesions of the 
spinal white matter are principally degenerative. 

Lesions of the Brain. — Pernice and Scagliosi 7 in diphtheric cases 
found the principal changes in the brain, cerebellum, and cord, and re- 
ferred them to circulatory disturbance followed by degenerative changes 
and hemorrhage. The cortical cells showed atrophic degeneration, 
which, as in the cord, especially affected their protoplasmic prolonga- 
tions. The well-known effects of alcohol and lead on the cerebrum are 
also found. Dehio, 8 experimenting on animals with poisonous doses 
of alcohol, found by appropriate stains that many of the cortical cells were 
changed in whole or in part. The presence of psychical symptoms in 
many cases of polyneuritis abundantly proves that the affection is one 
that does not spare the highest nervous apparatus. 

On the other hand, in many cases of polyneuritis no changes have 
been detected. Thus Hosche, 9 in a carefully examined case of wide- 
spread diphtheric palsy, found absolutely no change, even in the muscles 
which had been paralyzed. He, therefore, attributes the symptoms to 
toxins which operated without causing anatomical changes. The optic 
nerve, which is, in fact, a cerebral structure, is often affected in polyneur- 
itis. We have here to recall the whole list of toxic amblyopias. 
Alcohol again plays the most frequent part. The medulla and the 

i " Rif. Med.," Feb. 5, 1896. 2 « Rev> Men> des Mal de 1'Enfance " Sept., 1895. 

3 " Med. Rec," July 8, 1899. 4 " Br. Med. Jour.," Sept. 12, 1903. 

5 "Deutsch. Zeitschr. fur Nervenheilk.," Bd. 37, 1909. 

6 " Fortschritte der Medicin," 1896. ^ " Rif. Med.," Oct., 1895. 

8 " Centralblatt f. Nervenh. u. Psveh.," March, 1895. 

9 "Munch, med. AVochens.," March 12, 1895. 



320 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

cranial-nerve nuclei are subject to the same changes as the analogous 
portions of the spinal cord. 

Lesions in the Muscles. — The muscles supplied by the affected nerves 
in polyneuritis undergo changes similar to those in simple neuritis 
or in nerve-division, but usually less in degree. The escape of numer- 
ous fibrils in the nerve-trunks is probably to be correlated with the per- 
sistence of numerous apparently normal fibers in the atrophied muscles. 
Another and important feature, however, is added, and that is the ten- 
dency to fibrous hyperplasia in the affected muscles, constituting in well- 
marked cases an interstitial myositis, which, in its turn, may act detriment- 
ally upon the sarcode elements. This muscular fibrosis also explains in 
part some of the tendinous contracture deformities of late cases. The 
presumption is that an element of irritation is present which acts through 
the apparently normal nerve-fibrils, though Babinski is disposed to attrib- 
ute it to the pathogenic effect of the toxic agent directly on the muscle. 

Changes in the trophic and secretory functions of the nerve are, like 
the motor and sensory, less pronounced than in a simple neuritis, but 
do appear, and are marked by disappearance of the fatty panniculus, by 
thinned and glossy skin, vascular disturbances, mottling, edema, lack of 
perspiration, and by modified growth of hair, nails, and epithelium. 

Symptoms. — The symptoms arising from so wide-spread a dis- 
ease are correspondingly varied. It is necessary to take them up sys- 
tematically, but it may be said, once for all, that they are symmetrical, as 
a rule, affecting both sides of the body in a similar manner. This might 
be expected from a toxic cause of systemic distribution. It is, how- 
ever, a fact that the symptoms usually commence first on one side and 
frequently are slightly more marked on one side than on the other 
throughout the disease. They rnay be alternately exaggerated on the two 
sides. Some toxic agents, as lead, affect more especially the upper extrem- 
ities ; others, particularly alcohol, principally involve the lower. Again, 
in some cases the motor symptoms predominate ; in others, the sensory. 

Muscular and Motor Symptoms. — The Lower Extremities. — The 
motor disturbance in polyneuritis is principally one of deficit, a paresis 
that in severe cases reaches complete paralysis. It is most marked at 
the distal extremities of the limbs, and in the great majority of cases 
affects first and most the extensor muscles. In the lower extremity the 
extensors of the toes, the peroneal muscles, and the dorsal flexors of 
the foot are the ones usually most implicated. In marked cases foot- 
drop is complete. The foot falls into line with the leg and the plantar 
surface turns inward, passively producing an equinovarus position when 
the patient is recumbent, or when the foot is raised from the floor (Figs. 
115 and 116). In milder cases the patient can not raise the toes from the 
floor while standing on the heels, or, in other words, can not dorsally 
flex the foot beyond a right angle. The toes remain in a flexed, bunched 
position, and can not be extended or separated. Efforts against resist- 
ance at once disclose the weakness of these muscles. A peculiar and 
characteristic gait is developed. In order to clear the ground the patient 
is compelled to raise the foot by flexing the thigh. The leg is then 
thrown forward like a flail ; the toe is pendent ; the outer border of the 
foot is depressed and brought to the ground toe first, or in a flat-footed 



MULTIPLE NEURITIS. 



321 



manner, or the outer border of the foot strikes the floor first. The 
other foot is then advanced in precisely the same manner. From this 
high knee-action Charcot denominated the gait " steppage." The dang- 
ling foot sometimes wears the boot at the toe and frequently scrapes up 
the dirt of the pavement. In very rare instances a contrary position 
of the foot and an opposite sort of gait has been produced by loss of 
power in the calf-muscles, the anterior group being spared. The 




Fig. 115.— Drop-foot and deformities in alcoholic multiple neuritis. 



Fig 116.— Gait in mu 




ile neuritis, showing the high knee-action and tl 
its toe and outer border. 



foot descending by 



patient in such cases in walking brings the heel first to the ground 
with the foot everted and dorsally flexed. 

When the thigh-extensors are also affected and the muscles at the root 
of the limb are weakened, the use of the member becomes well-nigh 
impossible. A paresis of the extensors of the knee is often associated 
with that of the leg muscles in alcoholic polyneuritis. As above indicated, 
the loss of power may be trifling or absolute. While the muscle-groups 
enumerated are most affected, their opponents also lose power, but in 

21 



322 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

less degree. The loss of synergy alone would account for much of their 
weakness, but the neuritic process does not entirely spare them, and in 
severe cases of long standing they also waste. 

The Upper Extremities. — The distal segments of the upper ex- 
tremities, as in the lower limbs, are principally involved. The muscles 
of the forearms and hands are most affected. In polyneuritis the mus- 
cles under the control of the musculospiral are usually the first to suffer, 
the most involved, and the last to recover. Drop-wrist, the attitude 
characteristic of musculospiral palsy (see p. 301), is, therefore, a promi- 
nent deformity, and the disability of the hand conforms to this type, but 
the supinator longus often escapes. In some instances, to the drop-wrist 
is added the deformity characteristic of a median-nerve palsy, and the 
claw-hand or ape-hand is developed. The postcarpal tumor may also 
appear. In still rarer cases the deltoid, biceps, long supinator, spinati, 
and short supinator first suffer, but ordinarily they are involved, if 
affected at all, after the forearm- and hand-muscles have been invaded. 
These functional groupings of the palsies of polyneuritis again furnish 
us with evidence of the essentially nuclear character of the lesion. 

The trunk-muscles are sometimes also weakened, but only after the 
paresis of the extremities has become pronounced. Standing, walking, 
and even sitting may thereby be enfeebled or completely prevented. 

The muscles of the neck and face in very severe and extensive cases 
may also be affected, as may the muscles of the eyes, tongue, throat, 
larynx, diaphragm, of respiration, and of the heart itself. Involvement 
of the muscles of the throat, palate, and accommodative visual appa- 
ratus is a characteristic combination in diphtheric palsy. Brunton * 
calls attention to a mask-like face, frequently seen in the alcoholic 
variety of multiple neuritis, affecting particularly the portion of the face 
between the eyes and lips. 

Electrical Changes. — Owing, probably, to the variable amount of in- 
jury and irritation in the nerves, electrical tests in polyneuritis give all 
possible changes from the normal in different cases, and frequently at 
different periods in the same case. Not infrequently in the early days 
of the disease electrical excitability to faradic and galvanic currents is 
somewhat increased. This lasts but a short time, when diminished 
faradic response is presented, and may be attended in rare instances by 
voltaic diminution, a purely quantitative change. More frequently and 
customarily, as faradic excitability diminishes, the voltaic current aug- 
ments in power and eventually presents some or all of the items of the 
reaction of degeneration (see p. 47). Complete abolition of electrical 
response to the galvanic current is, however, rare, even in the severest 
cases. Popoff 2 contends that diminution of electrical responses may be 
detected long before paresthesia is noticed. Erb has noticed that with 
the increased voltaic responses sometimes myoidema can be easily produced. 
A sharp blow across the muscles with the handle of a percussion ham- 
mer, especially near the tendinous portions, produces localized contrac- 
tion of the muscle-fibers, causing a swelling that lasts for several minutes. 

Muscular atrophy follows the muscular enfeeblement, which in its 
turn is usually preceded by sensory disturbances. The muscular tone 

1 " Br. Med. Jour.," Dec. 1, 1900. 2 " Neurol. Centralbl.," 1900. 



MULTIPLE NEURITIS. 323 

sinks as the paralytic features develop and amyotrophia is promptly added. 
In rare cases the loss of power is pronounced and yet the muscular masses 
retain their usual conformation and electrical responses, but gradually 
their swelling curves are replaced by straight lines or even by hollows, 
and the wasting in extreme cases apparently denudes the bones of every- 
thing but the dermal and fibrous structures. A polyneuritis may stop 
at any point or attain any degree of intensity. The muscular atrophy 
necessarily shows corresponding variations. As the paralytic features 
preponderate in the extremities and particularly in the distal portion of 
the limbs, the amyotrophia is most marked in the same positions. We, 
therefore, find it ordinarily in the hands and feet, in the forearm and 
below the knee, but there is no voluntary muscle that may not be in- 
volved, and even the internal viscera are not immune. In some cases 
a thick layer of subcutaneous fat or an edematous condition may dis- 
guise the wasting of the muscles. 

Other Jlotor Disturbances. — The lack of muscular balance in some 
cases and the diminution of muscular strength, whenever pronounced, 
may be attended by a certain amount of coarse trembling, which is likely 
to appear on voluntary effort or when the muscles are strongly exerted. 
This, taken with the disturbed sensation, especially in the fingers, leads 
to much clumsiness in the smaller coordinate movements of the hand. 
Most patients early find difficulty in picking up small objects, buttoning 
their clothing, etc. For similar reasons they are not so precise in the 
use of the lower extremities, and from the loss of sensation in the feet 
they sway and sometimes fall in attempting to stand with closed eyes. 
The gait may also appear ataxic, but in the sitting or recumbent posi- 
tion these patients direct the movements of their lower extremities with 
as much exactness as their limited power will allow. The same is true 
for the movements of the upper limbs. The apparent ataxia must usu- 
ally be attributed to muscular weakness. Fibrillary tic itching in the 
atrophic muscles is frequently seen. Cramps sometimes occur upon 
effort being made after a period of repose, or spontaneously, or after 
the use of a comparatively mild faradic current. Patients very fre- 
quently complain of cramps, and of cramped positions. Hyperesthesia 
and other sensory disorders probably lead to such complaints. 

Contractures are very prone to develop. Their disabling character 
can not be too strongly emphasized, the more so as the malposition to 
which they give rise can usually be prevented by proper, earlv manage- 
ment. They arise : (1) In part from the lack of balance in the muscles 
on the two sides of the limbs ; (2) in part from the natural tendency 
of the flexors to impose upon the joints a position of demiflexion; (3) in 
part from the action of gravity, and (4) in great part from the develop- 
ment of the muscular fibrosis and fibrotendinous retraction in the mus- 
cles incident to the disease. From these causes the foot-drop becomes 
a fixture. Attempts to dorsally flex the ankle-joint are stopped abruptly 
by the rigid, shortened heel-tendon, which alone impedes the joint's move- 
ments. A similar condition is often present at the knee, elbow, wrist, 
and even at the hip and shoulder. In exceptional cases tenotomies are 
eventually required to enable the patient to put the heels to the floor. 

The Reflexes. — The cutaneous reflexes in the parts affected by a poly- 



324 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

neuritus may be normal, but are usually diminished in activity and 
sometimes abolished. The tendon reflexes are almost always diminished 
or abolished in the limbs that are most affected, but, of course, only in 
the muscles that suffer. The Achilles jerk may be abolished and the 
knee-jerk present, or there may be some difference on the two sides of 
the body. In well-marked cases, however, the ankle, knee, wrist, and 
elbow reflexes are usually greatly diminished and often wanting. Occa- 
sionally in slight cases, and then usually only at first, the reflexes may 
be very active, or even exaggerated, but clonus is never encountered. 
The organic reflexes governing the intestine and bladder are very rarely 
impaired and practically never abolished. Sphincteric control is, there- 
fore, maintained. 

Sensory Symptoms. — The sensory disturbances of polyneuritis are 
usually the first to appear, the last to cease, and they often, even more 
than the paralytic features, distress and worry the patient. Popoff, 1 
however, contends that reduced faradic reactions are the earliest symp- 
toms, and the author has foretold multiple neuritis in alcoholic cases by 
the diminished knee-jerks weeks before there was any complaint of pares- 
thesia. Most cases begin by paresthesia in the extremities, which the 
patients describe by such words as tingling, numbness, dumbness, pins 
and needles, coldness, heat, crawling, tickling, and similar expressions. 
They shortly notice that tactile impressions produce abnormal sensations, 
and it often requires careful questioning and examination to determine 
whether the condition is one of hypersensitiveness, blunted sensitiveness, 
or both combined. A light stroke with a feather may give rise to a dis- 
tinct sensation of tingling, when the patient can not tell whether he has »a 
small object, such as a pin, between the tips of his fingers and thumb, or 
may not be able to recognize such a familiar object by the sense of touch. 
As a rule, these sensory disturbances are persistent when once established, 
and only change gradually for the better or worse. In extent they present 
the greatest differences, depending upon the activity of the neuritis and 
its duration. Commencing usually in the finger-tips and in the toes and 
soles of the feet, they gradually extend up the limbs, enveloping them 
as if they were submerged in some loose material like cotton or shavings. 
Commonly the disturbance does not go above the elbow and knees, but 
may reach the roots of the limbs and invade the trunk. In a number 
of cases similar paresthesias are felt in the face, lips, and tongue at an 
early stage of the malady. 

As the disease advances, these persistent subjective sensory symp- 
toms become aggravated and frequently marked by crises of intense 
suffering, which are usually of the same character in a given case, but 
vary widely in different patients. One will complain of the most intense 
pain ; another suffers with burning sensations and wants cold applied ; a 
third feels that the extremities are cold to freezing and in a warm room 
bundles them with woolens. As a rule, when pain or sensory suffering 
is pronounced it is most marked in the lower extremities. It often 
deprives the patient of sleep and is an exhausting element in the case. 

Sensibility to touch, pressure, painful impressions, and temperature 
may also undergo marked changes, which are infinitely varied. The 
1 " Neurol. Centralbl.," No. 13, 1900. 



MULTIPLE NEURITIS. 325 

cutaneous sensations are disturbed in areas roughly corresponding to the 
paresthetic distribution and the motor loss. Early in these cases, when 
the irritative conditions in the nerve are probably at their maximum, 
there is a tendency to hyperesthesia. The patients may complain that their 
stockings feel as though full of knots, that the bedding feels as if made of 
ropes, and in various phrases express the exaggerated modifications of 
touch. Light contact may be painful. Pressure on the nerve-trunks and 
on the muscular masses usually develops marked tenderness, and in severe 
cases may evoke a painful crisis. In many marked cases some dissocia- 
tion of cutaneous sensations is observed. The pain and temperature 
sensations may be diminished more than tactile impressions, or touch 
may be abolished, the contact giving rise to pain or discomfort, which 
may not be properly located. In cases where the local conditions of 
wasting, anesthesia, and electrical tests indicate marked nerve-degenera- 
tion, the patient may still complain of pains, burning, etc. In late cases 
anesthetic features are nearly always present, but it is rare for them to 
reach a complete degree. Some modifications of the muscular and joint 
sense are also encountered, so that the blindfolded patient may have un- 
certain knowledge of the position of the limbs. The transmission of 
all forms of cutaneous sensation may be retarded, and generally all 
forms are uniformly decreased. 

Various toxic substances differ in the sensory disturbances they pro- 
duce. Some, with alcohol and grip at the head, produce marked painful 
disorders of sensation ; while others, of which lead and diphtheria are 
the chief, mainly cause motor impairment, — another argument for the 
central location of the disturbing element. 

Ocular Symptoms. — Msion. — Among the special senses, that of 
vision is the one principally, if not alone, affected. Many of the sub- 
stances capable of producing a polyneuritis also engender a toxic 
amblyopia. These are especially alcohol, lead, arsenic, and the carbon 
gases. (For the special symptoms which pertain to them, reference 
should be made to p. 108, and to special works.) It must be borne 
in mind that even a pronounced optic papillitis, retracted fields, color 
scotomata, and considerably reduced vision may foil to attract a patient's 
attention and must be intelligently sought. In the toxic cases the con- 
dition is bilateral and symmetrical, and usually of insidious development. 

Motion. — Squints and diplopia have been noted as frequently as once 
in ten times in diphtheritic neuritis (Remak) and occur also, but less fre- 
quently, in the alcoholic form. They are due usually to a neuritis of the 
oculomotor nerves, but sometimes to nuclear involvement, when they are 
commonly attended with apoplectic features and are of sudden onset. The 
motor nerves of the eyeball may be affected equally or singly, producing 
corresponding deviations, ptosis, etc. Commonly single muscles are 
paralyzed, a complete ophthalmoplegia being usually of nuclear origin. 

The Pupils. — In rare cases of polyneuritis the pupils have been 
affected. Dilatation, contraction, and inequality have been noted by 
various observers. The pupillary reflexes, however, are unimpaired, 
and the Argyll-Robertson phenomenon is not seen. Brunton contends 
that the pupillary response for accommodation is lost, that for light re- 
maining active, the converse of the Argyll-Robertson phenomenon. 



326 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

Accommodation is often disturbed in diphtheric neuritis, of which 
it is one of the most constant symptoms. Here, too, the pupils remain 
active. As a result of the paralysis of accommodation vision for near 
objects is reduced. This can be detected even in very young children 
by asking them to note a pin-hole in a calling card. For older 
patients printed characters are blurred and illegible. 

Trophic and General Conditions. — In addition to the muscular 
atrophy, the trophic disturbance is manifest in the extremities, especially 
toward the digits. The skin is ill-nourished, cold, muddy in com- 
plexion, often turgid and reddened. It is often glossy about the nails 
and the fingers are tapered with overhanging, claw-like nails, which the 
patient sometimes refuses to trim owing to the tenderness and hyperes- 
thesia. Edema is not infrequent and rarely an extra deposit of fat is 
encountered, as also in the condition named adiposis dolorosa by Der- 
cum, but ordinarily the fat disappears early. Perspiration is reduced, 
or more rarely increased, causing a sodden crumbling of the epidermis. 
The nails and hairs may become coarse, stiff, and fragile. Herpetic 
eruptions, erythema, and ulcerations, so frequent in an ordinary neuritis, 
are very uncommon. 

The general nutrition is usually greatly reduced and slight elevations 
of temperature are common. In the infectious forms fever may naturally 
be expected. The prolonged toxic or cachectic state, which usually 
antedates the onset of the polyneuritis, accounts for much of the physi- 
cal depression, but some of it is apparently due, and its continuance is 
partly attributable, to the lowered functional activity that pervades the 
entire nervous system. In severe and prolonged cases difficulty in 
swallowing, an inactive stomach and intestine, a weakened heart and 
failing circulation, the continuance of pain, with perhaps insomnia and 
mental disturbance, produce a marantic depression that ends fatally or 
destroys resistive power against acute infections such as pneumonia. 
But usually the general state can be maintained at a satisfactory level. 

Mental Symptoms. — Following Korsakoff, a number of writers have 
sought to delimit a psychosis peculiar to polyneuritis. It was pointed 
out by Colella 1 that such mental disturbance occurred only when 
the patient was hereditarily neuropathic. Among others, Ferrari 2 has 
shown rather conclusively that this so-called polyneuritic psychosis is 
merely the mental state that marks chronic poisoning by alcohol, lead, 
and other toxic substances, and has something in common with the con- 
fusional insanity that sometimes follows infectious fevers. Charcot 
maintained that it was related solely to alcohol, but Bury 3 has noted it 
in the Manchester epidemic due to arsenic in very moderate beer drinkers. 
Even here, however, an alcoholic influence can not be denied. However, 
the association of mental disturbance with polyneuritis is extremely com- 
mon and in slight degrees is easily overlooked. It is most often en- 
countered in the alcoholic variety, then in lead cases and the infectious 
multiple neuritides. In some cases the mental condition precedes the 
appearance of neuritic phenomena, but more commonly follows the onset 
of the polyneuritis and develops progressively with it. It is first manifest 

1 "Kivista Sperimentale, " vol. xx. 2 "Alien, and Neurol.," Jan., 1896. 

3 Log. cit. 



MULTIPLE NEURITIS. 327 

in a change of temperament and character. The patient becomes irrita- 
ble, capricious, and exacting, or may show apathy and indolence. This is 
attended or followed by loss of sleep and the nights are often marked by 
agitation and vague alarm, which subside with the day, to return at 
evening. Hallucinations develop as the malady advances and may 
lead, in the depressed and apprehensive mental state, to impulsive acts 
of a self-protective or defensive character. The patient may thus attack 
or abuse those about him or seek safety in flight. These marked men- 
tal symptoms may still subside toward morning, but finally in some 
cases the delirium persists night and day. When this cerebral condition 
occurs it usually appears comparatively early in the case, and corre- 
sponds, perhaps, to those irritative features that have been indicated in 
the peripheral nervous apparatus. Convulsions sometimes most clearly 
and emphatically demonstrate the cortical irritation. 

As the paralytic features develop in the limbs, a partially demented 
condition obtains for the cerebrum. Often the period of delirium and 
excitement is not evolved, and the depressed mental condition is insidi- 
ously developed primarily. This is marked most prominently by a for- 
getf tdness which pertains to the immediate past experiences and does not 
notably disturb the patient's recollection of events and conditions prior 
to the illness. Such a patient may talk rationally and logically on every 
possible subject, but is likely to forget what he has said or heard only a 
few moments previously, and repeats remarks and questions at short 
intervals or tells the same story over and over. Because of this 
amnesia he is frequently at fault as to the day of the week or month, 
or even the hour of the day, and may be unable to tell at noon what 
he had for breakfast. This is in most striking contrast with the 
patient's ability to remember the slightest details of his early life, with 
his apparent consciousness of his surroundings, and with his ability to 
logically associate facts presented to him. 

In addition one often observes what at first would seem to be the 
play of a diseased imagination. These patients may assert, perhaps when 
already confined to bed for months, that they are just returned from 
a long journey, of which they give endless and minute details, name 
persons encountered, repeat conversations held and business transacted, 
when they were, in fact, unable to turn over in bed. Such fabrications 
are recounted in the most ordinary way, without the slightest excite- 
ment, and completely forgotten in a short time. If we analyze them, 
we find a mass of more or less definite incidents or purposes transferred 
from the patient's past life and brought down to the date at which they 
are recounted, the intervening time having disappeared. Patients will 
speak of having just seen relatives long dead, or give directions for the 
entertainment of persons who may be in distant parts of the world. If 
their attention is called to these discrepancies, they first try to maintain 
their statements, but readily become mentally confused and uncertain. 

This amnesic mental condition may be developed in all grades of 
intensity, and may even proceed to complete dementia and a fatal termina- 
tion. The bodily strength and powers of assimilation usually are cor- 
respondingly depraved. The mental disorder passes away as the case 



328 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

mends, and the mind is usually perfectly clear before the peripheral 
apparatus is fully restored. 

Course and Special Forms. — Polyneuritic cases present many clin- 
ical varieties and some special forms. An ordinary case may be outlined 
as follows : The first complaint is of tingling or formication in the feet 
and legs, with occasional pains. After a few weeks the hands and fore- 
arms are similarly affected and some slight loss of muscular strength is 
recognized. The sensory and motor troubles increase. Pain becomes 
more prominent and the paralytic features invade the thighs, hips, and 
perhaps the trunk and arms. After about eight weeks the malady is 
full-fledged. The patient now walks with the high action, the muscles 
of the extremities are notably wasted and give the electrical reaction of 
degeneration, foot-drop and wrist-drop are well marked, and the reflexes 
are diminished or abolished. The patient is uncertain on his feet, the 
legs and feet readily become edematous, red, and livid ; with closed eyes 
he sways and perhaps falls. In bed, from the weakness in the arms 
and trunk, he can not gain the sitting posture without help. The mus- 
cles and nerve-trunks are sensitive to pressure ; there is some anesthesia 
or at least much blunting and retardation of the cutaneous sensations, 
and much sensitiveness in certain cases. The skin is dry and thinned 
about the digits and base of the nails. At this time mental disturb- 
ance is likely to appear. After this state is reached the case remains 
almost stationary for several months ; then the sensory disturbances 
diminish slowly, the pains decrease, the anesthesia disappears ; the 
muscles regain their former proportions, strength, and reactions ; the 
reflexes reappear, and full recovery is established, after about twelve 
months from the onset of the disease. Very often anesthetic areas be- 
come hyperesthetic and the pains increase as regeneration passes down- 
ward. In some instances the disease, instead of coming to a standstill, 
progresses to a fatality by involving the muscles of the trunk, of respira- 
tion, deglutition, and circulation. Death results from pneumogastric 
involvement. In other cases the development of fibrotendinous con- 
tractures disables the patient after convalescence until surgically relieved. 
Again, the progress of the disease may be much varied. It may com- 
mence insidiously and then advance with great rapidity, or, commencing 
suddenly, quickly reach its maximum and then slowly or quickly sub- 
side. When atrophy is well marked, restoration is always a tedious 
affair. As a rule, in the cases that recover full health is regained, but 
in a few cases localized atrophies and contractures remain permanently. 

Other clinical varieties depend on the location of the prominent symp- 
toms of the disease. The cranial nerves, the upper extremities, or the lower 
limbs may be most affected. Some cases show a preponderance of motor 
disability, others of sensory disturbance. The rare cases marked at first 
by increased reflexes, increased electrical responses, marked hyperes- 
thesia, and perhaps a tendency to delirium, must not be overlooked. 

In addition there is a small group of very acute cases in which the 
disease, beginning in the feet and legs, rapidly invades the thighs, the 
trunk, the upper extremities (commencing in the fingers and gradually 
passing up the limbs to the shoulder), and, finally involving the dia- 
phragm and the bulbar nerves, reaches a fatal temination in from six 



MULTIPLE NEURITIS. 329 

to twenty days. By some writers this form is considered identical with 
Landry's paralysis, but by others is distinguished from it by the disturb- 
ance of sensation and reflexes and the postmortem presence of changes 
in the nerve-trunks. Any sharp distinction is arbitrary and untenable, 
as all gradations between multiple neuritis and acute ascending myelitis 
are encountered. 1 

Certain toxic elements cause a polyneuritis marked by peculiar and 
even characteristic symptom groups that merit brief attention. 

The alcoholic form, besides being the most usual polyneuritis, 
presents with considerable uniformity the following features : The 
lower extremities are the most affected, and the painful sensory dis- 
turbances reach their highest range in this toxic state. They are pro- 
portionately much more pronounced than the paralytic conditions. The 
paresthesia? are particularly intense and intolerable. The muscles and 
nerves are especially sensitive, and cutaneous hyperesthesia is exquisitely 
developed. The high-action gait is usually well marked, as the exten- 
sors of the leg are generally affected with the muscles below the knee. 
Atrophy is well marked and the tendency to fibrotendinous contracture 
is very strong. Involvement of the ocular muscles is comparatively 
frequent and bilateral scotomatous amaurosis is common. Of all forms, 
alcoholic polyneuritis furnishes by far the greatest number of cases of 
mental disturbance. Recovery is comparatively rapid if alcohol can be 
withdrawn. Relapses are probable, and a single indulgence before the 
disease is definitely at an end may cause the most startling reappearance 
and exaggeration of all the former symptoms. 

Lead-palsy in typical cases presents some or all of the following 
conditions : It usually comes on after prolonged exposure to intoxication 
through the patient's occupation, or by the use of drugs and cosmetics, 
or by drinking contaminated water. The source of the lead-poisoning 
is often extremely puzzling and requires the most painstaking search. 
The paralytic features are usually preceded by colics and constipation, 
and may develop at a long period of months after the patient has been re- 
moved from the source of intoxication. In other cases the administration 
of alkaline iodids to one impregnated with lead, but showing no marked 
svmptoms of it, may precipitate the neuritis. The upper extremities 
are first and almost exclusively affected. In children, however, the lower 
extremities may suffer equally. The distribution of the palsy is prac- 
tically symmetrical, but the right hand is most disabled in right-handed 
patients, the opposite hand in the left-handed. Sensory disturbance 
in the hands is practically absent, but if the legs are affected cutan- 
eous sensibility is changed and pains are usually present below the knees. 
The muscular wasting is prominent, and in some cases seems to be the 
primal disorder, bringing these cases into apparent relation with the 
myopathies. Most cases show the wrist -drop feature, but arm and 
shoulder types may be encountered alone or may be gradually added to 
the first form, establishing an appearance of relationship with the spinal 
myopathies. The muscles of the larynx are frequently affected, as 
shown by aphonia. The retrocarpal tumor is usually developed. Ocular 
disturbances are frequent, and due to optic neuritis, from which sudden 
1 Medin, "Arch, de Med. des Enfants," 1898. 



330 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

blindness may occur. When the trunk and bulbar muscles are involved, the 
outlook is better than in the alcoholic varieties under similar circumstances. 
The course is usually insidious at the beginning and protracted throughout. 

Lead-palsy also has its associated mental disturbance. In rare cases 
this resembles the one so usual in alcoholic polyneuritis sketched at page 
326, with marked visual hallucinations and amnesia. Lead, however, has 
its own cerebral disorders. These are an acute mania and a condition 
that presents all the somatic indications of general paresis, but is usually 
marked by mental sluggishness and is devoid of the expansiveness of 
true paretic dementia. In addition lead may engender general cerebral 
affections by its action on the circulation, mainly by the arteriosclerosis and 
kidney disorders it induces. Delirium, convulsions, coma, hemiplegia, 
and combinations of these are frequently encountered in plumbism. 

Diphtheric Paralysis. — The term paralysis is selected purposely, 
as a neuritis can not always be demonstrated in these cases. Hochhaus 
found only the muscles aifected, and Babinski, in rabbits paralyzed by 
injections of the toxins derived from the Klebs-Loffler bacillus, found 
no changes whatever. In certain cases, however, a periaxial neuritis 
is clearly demonstrable. What the conditions are that determine a 
neuritis in one case and leave no trace in others can not now be stated. 
The result in both instances is undoubtedly due to the action of the 
toxins evolved in the life-history of the bacillus of diphtheria. Eoemheld x 
calls particular attention to the increase of albumen in the spinal fluid 
and the lymphocytosis therein present, both of which improve with the 
general improvement. Diphtheric palsy may appear after all forms of 
the initial malady, whatever its apparent intensity or bodily location. 
Ware, for instance, reports a typical case with the usual pharyngeal palsy, 
the diphtheric membrane being located on the vulva. It seems to be 
rather more common in adult cases, perhaps because the palatal, pharyn- 
geal, and pneumogastric involvement in infants may lead to a fatal ter- 
mination without being attributed to a nerve-lesion. Ordinarily, it appears 
during convalescence in from one to three weeks after the diphtheria 
has subsided, but may develop within a day or two of the appearance of 
the pseudomembrane. The muscles of the soft palate and the pharynx 
are the first to suffer, as a rule, and the paralysis may extend to the lips, 
cheeks, and tongue. If it spreads further, the legs next suffer. The 
knee-jerks are often abolished, even before the palate is disturbed. The 
upper extremities and the trunk are invaded only in exceptional cases. 
The muscles of the neck, on the contrary, are frequently weakened, so 
that the head may roll about helplessly on the shoulders. The affected 
muscles rarely waste and contractures hardly ever develop. Sensory 
changes consist of insensibility in the affected parts, as in the pharynx, 
larynx, etc. Much pain and painful paresthesia are wanting. There 
is usually some ataxia in the extremities and Romberg's sign is seen. 
At the time the palatal difficulties appear there is usually some loss of 
visual acuity, especially for near objects, which is due to the character- 
istic paralysis of accommodation, but the pupils do not fail to act. 
Strabismus, double vision, and ptosis are not uncommon. In adults, 
sexual impotence is frequently developed. Mental symptoms almost 
1 " Deutsch. Zeitschr. f. Nervenheilk.," Dec, 1908. 



MULTIPLE NEURITIS. 331 

never occur. Diphtheric palsy is of rapid development and usually 
terminates in recovery. If only the palate is affected, cure is reached 
in two or three weeks ; in more generalized forms the disability is pro- 
longed to three or four months, or even to a year in severe cases. If 
death occurs, it may be attributable to the cachexia and inanition from 
inability to swallow or may be caused by pneumogastric paralysis. In- 
spiration pneumonia is also likely to carry off the patient. In very rare 
cases of diphtheric palsy the paretic features are fleeting, and change 
from place to place or disappear and return. These cases are more 
frequent since the general use of antitoxin in the treatment of diph- 
theria, probably because cases are now saved that otherwise would have 
terminated fatally. 

Erythromelalgia is a variety of multiple neuritis affecting princi- 
pally the plantar nerves, and first described by Weir Mitchell as a vaso- 
motor neurosis. Collier 1 reports ten cases of erythromelalgia in organic 
nervous disorders : six of insular sclerosis, three of tabes, and one of mye- 
litis. It may also occur with decided arterial changes, but undoubtedly 
is a neuritis, as proven by Mitchell and Spiller. 2 It usually attacks men, 
and is worse at night and after walking. The feet become intensely red 
and show some swelling. The pain is of a burning sort and the attend- 
ing perspiration may be profuse. Heat aggravates and cold relieves the 
distress. Elevation of the feet also affords relief. Walking may be- 
come so painful as to be impossible. Trophic disturbance in the skin 
in severe cases is encountered. The condition may get well spontane- 
ously or be very persistent. Rest in bed, electricity, massage, and, in pro- 
tracted cases, excision of the posterior tibial nerve have been advised. 

Beri-beri, or kakke, is a polyneuritis that apparently depends upon 
a specific infection. Several investigators have found various micro- 
organisms which they have thought to be the pathogenic agents, but 
there is as yet a lack of uniformity and confirmation. There are- those 
who insist that it is due to carbonic gas poisoning. Others have attrib- 
uted it to a diet of fish or rice. Polished rice, or that denuded of the 
pericarp, is supposed to be particularly objectionable, the difference being 
attributed to the removal of the phosphorus compounds. It arises when 
people are huddled together in prisons, asylums, barracks, or on ship- 
board, and is particularly common in China, Japan, and India, and in 
South and Central America. It is marked by paralytic and atrophic 
disorders, especially in the lower limbs, and particularly in the antero- 
external leg muscles, producing the characteristic gait. The phrenic and 
pneumogastric nerves suffer early, and respiratory and cardiac symptoms 
are prominent. The face and tongue are frequently affected. The sen- 
sory disorders are mainly anesthesia and severe, lightning-like pains. 
Edema of the lower extremities is often very great. It may also invade 
the trunk and flood its cavities. The knee-jerks are lost early. There 
is frequently right cardiac dilatation, rapid heart action, and murmurs 
over the base. Mental disturbance, similar to that in alcoholic cases, 
is frequently observed. All degrees of severity, from simple weakening 
of the lower extremities, with cardiac palpitation, to a pernicious acute 
form, like an acute ascending myelitis that runs to a fatal termination 

1 " Lancet," Aug. 13, 1898. 2 "Am. Jour. Med. Sci.," Jan., 1898. 



332 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

in a few days are presented. Intermediate varieties may be marked 
most by atrophy or by edema, and are very long in recovering, with 
death always likely from pneumogastric accidents. A large proportion 
of cases are said to have intestinal parasites. H. Wright 1 found 
changes in the cells of the posterior root ganglia and the anterior horns 
of the cord in eight consecutive cases. He says: 2 "It is an acute or sub- 
acute infectious disease, due to a specific organism not yet certainly deter- 
mined; the organism is not one whose special habitat is any food such as 
fish or rice, but one that may nevertheless be ingested in any food and 
drink accidentally contaminated; that, after gaining an entrance to the 
alimentary canal, the organism multiplies in the contents of the stomach 
and small gut, but chiefly in the contents of the duodenum; that it there 
elaborates a toxin which, being absorbed, poisons certain afferent and 
efferent neurones to different extents and in different degrees, and thus 
gives rise to a group of symptoms which can be classified as acute per- 
nicious, acute, and subacute beri-beri. The probable duration of the active 
stage of the organism is from two to six weeks, and after its active stage 
has ceased and its virus has been eliminated, the paresis or paralysis it 
has engendered persists." For this persistent paralysis he has proposed 
the term "beriberic residual paralysis." 

Tsuzuki 3 claims to have demonstrated a specific microorganism from 
the urine and feces of beri-beri sufferers, a diplococcus which produces 
similar symptoms in animal experiments. 

Leprous Neuritis. — The invasion of the nerves by the leprous 
bacillus sets up a multiple neuritis or more properly a polyneuritis. 
There is a marked tendency to fibroid proliferation in the nerve-trunks, 
which often become nodular, and eventually the bacilli disappear. The 
spinal cord is exceptionally invaded by the bacillus (Souza, Martius), and 
presents central cavities, especially in the posterior horns and gray com- 
missure. The prominent sensory disturbance is anesthesia, which occurs 
in discrete plaques, favoring in location the hands, feet, forearms, legs, and 
face. By spreading, an entire member or a large portion of the body may 
become anesthetic, and the deep parts, muscles, bones, etc., are also in- 
volved. Muscular atrophies are comparatively slight, and most affect the 
small muscles of the hands, feet, and face. Atrophic conditions in the 
hands and feet lead to mutilations of the extremities. Fingers, toes, and 
even hands and feet necrose and are cast off. The evolution of the neuritis 
is extremely slow, and may extend over a score of years. 

In some cases a dissociation of cutaneous sensation is encountered 
similar to that of syringomyelia, especially of the Morvan type, and 
probably due to the cord lesions previously noted. 

Recurrent multiple neuritis as a variety has been described by 
Sherwood, Ross, Dreschfeld, Targlowa, Klumpke, and Osier. Thomas 4 
also reports a case. It appears that certain individuals are susceptible 
to repeated attacks from various poisons, but particularly from lead 
and alcohol. It is not requisite that the patient be exposed to the 
intoxicant to induce a recurrence of the neuritis, and it is unde- 

1 " Br. Med. Jour./' June 29, 1901. 2 " Br. Med. Jour.," Nov. 11, 1905. 

3 " Archiv. f. Schiffs u. Tropen-Hygiene," July, 1906. 
4 " Phila. Med. Jour.," May 14, 1898. 



MULTIPLE NEURITIS. 



333 



termined whether there is an original susceptibility or the first attack 
leaves a predisposition to its return. 

Diagnosis. — The diagnosis of a case of well-marked multiple neu- 
ritis, based upon a fairly full history and a detailed examination, can 
hardly be missed ; but in the early stages, when a diagnosis is of most 
importance, it is frequently extremely difficult. The major items upon 
which it then rests are the motor and sensory symptoms, their sym- 
metrical distribution, their predominance in the ends of the extremities, 
the more marked affection of the extensors, the modification of the 
reflexes, the tenderness of nerve-trunks and muscles, and the history 
or presence of some toxic agent capable of producing the neuritis. A 
multiple neuritis may be confounded with several diseases of the spinal 
cord, especially poliomyelitis anterior and locomotor ataxia. The fol- 
lowing differential tables may help to distinguish them : 



Poliomyelitis. 

Most frequent in children. 
Onset abrupt. 
Embraces entire limbs. 
Not usually symmetrical. 
Immediate tendency to improvement 
Sensory symptoms slight or absent,, 
No mental symptoms. 
Usually leaves some deformity. 



Multiple Neuritis. 

In adults. 

Insidious. 

Begins in ends of limbs. 

Symmetrical. 

Gradual extension. 

Sensory disturbance early and persistent, 

Mental symptoms common. 

Recovers completely. 



Locomotor Ataxia. 
Girdle pains and lightning pains early. 

Nerve-trunks often insensitive. 

Muscular sense disturbed early. 

Amyotrophia, and reaction of degenera- 
tion absent. 

Peculiarity of gait due to incoordina- 
tion and irrespective of muscular 
strength . 

Strikes heels first and does not follow 
straight line. 

Circulation and trophic condition of 
limbs normal. 

Perforating ulcers, joint lesions, and oste- 
opathies are common. 

Argyll-Robertson phenomenon usual. 

Optic atrophy common. 

Vesical doubles frequent and early. 

Gastric and intestinal crises. 

Fecal incontinence common. 

Sometimes followed by paretic dementia. 

Of slow evolution, requiring years. 

Incurable. 

Syphilis usually in the history. 



Multiple Neuritis. 

No girdle pains ; lightning pains infre- 
quent. 

Usually oversensitive and often thick- 
ened. 

Only slightly disturbed or intact. 

Develop early. 

Due to paresis and proportionate to 
loss of power. 

Strikes toes and outer border of foot 
first and walks in straight line. 

Muscular atrophy, edema, lividity, and 
epithelial changes. 

Rare or unknown. 

Never present. 

Rare, but toxic amaurosis frequent. 

Very exceptional and late. 

Dyspepsias from toxic causes, consti- 
pation from lead, etc. 

Only in acute pernicious cases and in 
stuporous states. 

Often accompanied by mental disturb- 
ance. 

Of insidious, progressive develop- 
ment, requiring months. 

Recovers if patient survives. 

Antecedent intoxications, infections, and 
cachexias. 



Myelitis is distinguished from polyneuritis by the girdle pains, the 
paraplegia, the anesthesias, the retention of electrical responses in many 



334 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

of the paralyzed muscles, and the presence of the deep reflexes, which 
usually are extremely exaggerated. In this disease bedsores are com- 
mon ; in polyneuritis well-nigh unknown. The sphincters are usually 
beyond ordinary control in myelitis and practically unaffected in neuritis. 

Hysteria is sometimes confounded with polyneuritis, and, indeed, both 
may be present in the same patient, but should none the less be separately 
recognized. The pain in hysteria lacks sincerity of facial expres- 
sion and the deep muscular masses are practically never sensitive. 
Hysterical anesthesia is segmental, and rarely involves all four extrem- 
ities symmetrically. The reflexes and electrical reactions are present in 
hysteria — there is no wasting, no cutaneous dystrophy. The evolution 
of hysterical trouble, its emotional concomitants, and its stigmata are 
sufficiently significant. 

The pernicious anemias often present reduced reflexes, paresthesias in 
the extremities, uncertain gait, mental vagueness, and general muscular 
weakness. A careful blood examination shows characteristic cellular 
changes (see page 466). 

The diagnosis of the toxic cause and its origin is usually made in 
securing the history or in making the examination of the patient, but 
many times presents great and even insuperable difficulties. The alco- 
holic, lead, and diphtheric types of polyneuritis are themselves signi- 
ficant of their origin. Alcoholic addiction is frequently denied, espe- 
cially by women. Patients may even be unaware that they are taking 
large quantities of alcohol in the form of various nostrums and patent 
medicines. The absence of the lead line on the gums should not mis- 
lead, as it only occurs where there is some local disturbance about the 
necks of the teeth. A dose of iodid, followed by an analysis of the 
urine, may show plenty of lead. Hair-dyes, face-powders, and styptic 
applications or injections may contain lead, and the polyneuritis may 
appear several months after their discontinuance. Arsenic and lead in 
fabrics, paints, wall-paper, toys, and medicinal prescriptions are to be 
borne in mind. In diphtheria, if the patient has been exposed, it is not 
necessary to have a pseudomembrane or even a history of a sore throat 
in order to attribute the palsy to the proper source. Leprosy and beri- 
beri are distinguished by their infectious and clinical peculiarities. 
There remains the great class of infections arising from intestinal fer- 
mentation and the infectious diseases, which must be deciphered from 
the history and examination of the patient. 

Prognosis. — It may be laid down as a general rule that if the cause 
of a polyneuritis can be removed, the patient has a very good chance of 
complete recovery, and that recovery is the most common termination 
of the disease. The prognosis is to be modified in accordance with the 
nature of the pathogenic agent, the mode of evolution of the disease, 
its intensity, extent, and localization, and the general physical condition 
of the patient. Diphtherial polyneuritis, unless the patient succumbs 
in the early days of the attack, is the most benign form, and rapidly 
terminates in recovery. Lead palsy alone very rarely causes death, but 
is usually attended by a bad general state and is of long duration and a 
disabling character. Alcoholic neuritis is more frequently fatal and is 
customarily associated with other organic disease due to the same cause. 



MULTIPLE NEURITIS. 



335 



The intense painful conditions that attend it and the debilitating suffer- 
ing, with the tendency to mental disturbance, give to the alcoholic form 
a high grade of gravity. Auto-intoxication arising from the intestine usu- 
ally is the result of chronic and intractable bowel disease, and is corre- 
spondingly protracted and unmanageable. Acute invasion and rapid 
evolution of a polyneuritis lead at once to the apprehension of respira- 
tory and cardiac failure and an early fatal termination. On the other 
hand, an insidious onset and slow advancement imply chronic tenacity 
and a prolonged impairment of powers, with slow convalescence. 

The gravity of a polyneuritis is in some proportion to its extent, par- 
ticularly in relation to its advancement toward the trunk, implying great 
helplessness, and toward the pneumogastric, implying fatal accidents 
from its implication. The presence of cerebral symptoms, such as psycho- 
ses or convulsions, and of 
spinal involvement, as shown 
by loss of sphincter control, 
add greatly to the gravity 
of the outlook. The general 
state, the powers of diges- 
tion, assimilation, and the 
ability to sleep have a strong 
bearing on the recuperative 
prospects of the patient. 

Treatment.— The first 
element in the treatment of 
a multiple neuritis naturally 
is the removal of the cause. 
In alcoholic cases this is fre- 
quently a matter of great 
difficulty unless the patient 
can be placed under the care 
of a trained nurse or in a 
hospital. In some instances 
the immediate withdrawal 
of alcohol is attended with 
a great deal of physical and mental disturbance, but half-way measures 
usually only prolong the agony and frequently fail completely. After 
such a case has made decided improvement and if taken early this may 
promptly appear ; a very little indulgence in alcohol is likely to cause 
the return of all former symptoms. Very moderate drinking is capable 
of maintaining them indefinitely. 

Lead can be eliminated from the system by the use of the alkaline 
iodids and sulphates, but some care must be taken not to liberate the 
metal too rapidly, as cerebral disturbance and an increase of the paralytic 
features may be precipitated. They should be commenced in small but 
increasing doses, and aided by elimination from the skin, kidneys, and 
especially from the constipated bowels. Occupations giving rise to such 
poisoning must be given up entirely, as even when convalescence has 
been long established a relapse is likely to quickly follow a return to 
the former work. 




117.— The upper figure represents the shape of the 
brown-paper pattern, and of the leather cut in correspond- 
ence to it. The dimensions are approximate, varying with 
each leg; d is the narrowing for the knee, that the leather 
may not press on the hone at the sides; b is the excavation 
on each side for the ankle with the narrow connecting piece 
of leather, which is the special feature of the contrivance. 
This, 1 to 1% inches wide, and no longer than is needful, 
affords lengthwise, adequate support to make the pull from 
above act down on the foot-piece on which the pull acts : at 
h and g are the rings for the cords; the cords are here 
shown only as going to the lower rings ; if there i~ contrac- 
tion of the knee, they should he carried through these rings 
and fastened to the other rings above the knee; if there is 
no contraction of the knee, it is not necessary for the leather 
to extend above the knee (after (lowers). 



336 DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 

In auto-intoxications from intestinal fermentation a restricted diet and 
the use of those antiseptics which tend to inhibit bacterial activity and 
reduce toxicity are indicated. In diphtheria the source of infection 
subsides with the cessation of the bacillary invasion. In the poison- 
ings following acute infections the toxemic state requires attention and 
is best controlled by very large doses of iron, especially the tincture of 
the chlorid, by salol, and similar drugs. If a malarial element is pres- 
ent, quinin and arsenic are required. The various cachexias that are 
attended by the development of multiple neuritis unfortunately are rarely 
amenable to treatment. In tuberculosis and cancer, the measures which 
produce improvement in the general state benefit the neuritis. 

The general physical condition in all cases requires attention from 
first to last, and one of the chief items in this connection is rest for the 
weakened muscles. This frequently means rest in bed. In all marked 
cases such rest is obligatory. In the acute cases that rapidly involve 
respiration and threaten the pneumogastric the greatest care must be 
taken to prevent pneumonic inflammation. At the same time the alimen- 
tation and support of the patient's strength frequently require the use 
of the esophageal tube by the way of the nose or mouth, or rectal feed- 
ing may be employed. From first to last, also, measures must be taken, 
especially in alcoholic cases, to prevent contractures and posture deformi- 
ties. These usually are confined to the lower extremities. Foot-drop 
and inversion of the sole constitute the ordinary deformity, but the knees 
and hips are also frequently involved in a semiflexion made rigid by 
tendinous contractures and rarely by joint-adhesions. The weight of 
bed-clothing serves to increase the foot-drop, and must be taken off the 
toes. So far as possible the feet should be kept at a right angle with 
the legs and the knees and hips extended. The sensitiveness of the 
skin and the pains in the limbs often defeat attempts to use any fixation 
apparatus such as light splints, but if commenced early, they can often 
be worn with great advantage. Pillows may be so placed as to support 
the feet and remove the weight of bed-covering. Passive movements 
in full extension and especially full dorsal flexion of the feet on the legs 
should be gently used several times daily. 

In early stages the use of hot or cold applications has been recom- 
mended, but probably does little good, aside from slightly relieving 
the pain. Vesication and strong stimulation by counterirritation must 
be avoided, owing to the likelihood of producing indolent ulceration. 
Vigorous massage and electrization that produces firm contraction of 
the muscles are also contraindicated at first. Gentle strokings or 
kneadings of the muscles that do not cause pain or distress are often 
very grateful to the patient, aid return circulation, and favor local nutri- 
tion. Hot baths, needle douches, Turkish and Eussian baths, and vig- 
orous measures generally should be reserved until the disease has passed 
its maximum, 

The question of anodynes here, as in sciatica and other prolonged 
painful affections, is one requiring mature judgment and great conserv- 
atism. The coal-tar derivatives sometimes act well and are not so 
objectionable as opiates and cocain, which alone seem capable of con- 



HERPES ZOSTER. 337 

trolling the pains in the severest cases. Chloral and bromids combined 
are the surest sleep-producers. 

After the disease has reached its stationary period more vigorous 
local measures should be instituted. Massage of the weakened muscles 
and their exercise by galvanic electricity should be faithfully and sys- 
tematically carried out once or twice daily. The wasted muscles 
frequently respond to static sparks before they will to the constant cur- 
rent, and this form of electricity, if available, will then render good 
service. A faradic brush or static sparks also seem to beneficially 
influence cutaneous anesthesia and hyperesthesia. The patient must 
be urged to use the limbs, and at the first possible moment to bear 
weight on the feet and get the heels to the floor. 

In cases of long standing, when the contractures are strongly devel- 
oped, stretching, under anesthesia, and the application of fixative dress- 
ings may be done, and, if this does not suffice, tenotomies are in order. 
In chronic cases of wrist-drop the use of splints, as described on page 
299, will often be found of signal service. Here, too, courses of hot 
baths, especially if combined with intelligent massage, hot douches, the 
Scotch douche, and Turkish baths, are serviceable if the general condi- 
tion of the patient does not contraindicate their use. 



CHAPTER V. 

HERPES ZOSTER. 

Herpes zoster, also known as zoster, zona, and more commonly as 
shingles (Lat. cingulum), is an acute infectious disorder beginning with 
pain, soreness and burning in a given segmental skin area, followed by 
discrete groups of papules on a reddened and swollen base, after a few 
days showing turbid and purulent contents, and later brown crusts which 
fall by the end of the second week, leaving reddened or pigmental 
patches and occasionally scars. There is sometimes fever in the initial 
stage which with the pain subsides upon the appearance of the eruption. 
Secondary infection of the eruption may complicate the course and 
termination of the disease. The lesion is an acute hemorrhagic inflam- 
mation of the corresponding posterior root ganglia. The favorite loca- 
tion is on the head or face and about the trunk, but any portion of the 
cutaneous expanse may be affected. 

Etiology. — The exact nature of the infection in herpes zoster is 
not yet determined, but it presents seasonal, epidemic, contagious and 
self-limited peculiarities. To this infection, or the toxin therefrom 
arising, the posterior root ganglia show a decided susceptibility, but 
commonly one only is affected in a given case. Certain ganglia, more- 
over, are more prone to attack than others, namely, the Gasserian and 
those from the third dorsal to the second lumbar spinal roots. These 
are in relation with the gastro-intestinal tract by sympathetic afferent 
fibers. A similar eruption appears if the ganglion be secondarily in- 
volved in any inflammatory or destructive process, and injury to a 

22 



338 



DISEASES OF SPINAL MENINGES AND SPINAL NERVES. 



nerve-trunk may also cause a herpetic eruption limited to its cutaneous 
distribution. Zoster sometimes occurs in connection with malaria, 1 
typhoid, meningitis, and pneumonia, and after arsenical, carbonic oxid 
gas, and intestinal poisonings. Second attacks are so rare as to lend 
support to the idea that immunity is afforded by the first invasion. 
Herpes zoster is also frequent in tabes and paretic dementia, both of 
which commonly involve root ganglia. 

Pathology. — Barensprung first found that zoster was associated 
with inflammatory changes in the nerve and ganglia. Head and Camp- 
bell 2 have placed the matter on a secure foundation. In all well- 
examined cases an acute inflammatory condition is found in the ganglion 
with bloody extravasation, destruction of cells and fibers, and inflam- 
mation of the sheath. These are followed by acute degeneration of 
greater or less amount and even by secondary sclerosis. In the per- 
ipheral nerves degeneration 
appears and disappears or 
may terminate in sclerosis 
pari passu with the change 
in the ganglion. The nerve 
changes are secondary to 
the ganglionic invasion, but 
an active hemorrhagic in- 
flammation may extend into 
the nerve from the ganglion. 
The spinal cord presents 
acute degeneration of the 
root fibers in the posterior 
column, appearing about the 
tenth day of the disease. 
The vesicles of the skin 
eruption contain a sterile 
serum, and no evidence of 
bacterial invasion is found in 

Fig. 118.— Herpes zoster confined to the fifth and sixth dorsal the neighboring profoundly 

segments. inflamed lymphatics. 

The disease may be considered as analogous to poliomyelitis anterior 
acuta, and the authors quoted have proposed for it the name acute 
posterior poliomyelitis. 

Symptoms. — Zoster furnishes, according to Max Joseph, 3 about 
one per cent, of all so-called skin diseases, attacks both sexes equally 
and mainly between the ages of fifteen and thirty years. Both sides 
of the body are affected with equal frequency, but bilateral herpes 
zoster is extremely rare. There is an old superstition that should 
shingles entirely girdle the body it would be fatal. As a matter of 
fact, bilateral herpes zoster is usually due to serious disease of the 
vertebral column such as cancer or destructive Pott's disease. Epidemics 
of zoster occur in the spring and autumn, but sporadic cases appear 




1 Winfield, "N.Y. Med. Jour.," Aug. 2, 1902. 2 "Brain," Dec, 1900. 

3 "Phila. Med. Jour.," Oct. 25, 1902. 



HERPES ZOSTER. 



339 



with regularity throughout the year. There is a prodromal period of a 
few days with malaise and slight temperature. Pains, sometimes in- 
tensely neuralgic, burning, discomfort, uneasiness in varying degree, are 
felt in the part and suddenly the eruption appears. Commonly, pain 
and temperature then subside and the eruption runs its indicated course. 
Not infrequently, from infection of the eruption by various applications 
or the fingers, sloughs and even gangrene may result, but ordinarily under 
any cleanly management the blebs dry up and no serious scarring results. 

The distribution of zoster is peculiar and significant. On the head 
and face it folloAVS the distribution of the three main branches of the 
fifth nerve very closely in some instances and rarely invades the fields 
of two of them in one patient. More commonly it is confined to a patch 
within the territory of a single branch and located at the so-called max- 
imal point of the segmental area 
outlined by Head (see page 60). 
On the trunk the eruption is 
either massed about the maximal 
points of pain in the segmental 
areas related to the spinal cord, 
or, as in the case illustrated, fol- 
lows the limits of such area pre- 
cisely. When occurring on the 
extremities, the eruption follows 
the longitudinal lines of the cord 
segments. The eruption does not 
follow peripheral nerves and their 
cutaneous distribution unless aris- 
ing from injuries or inflammation 
of such nerves. 

Diagnosis. — The diagnosis 
is very readily made, only vesic- 
ular eczema and simple herpes 
are likely to be confounded with Fi §- 119 - 
it. The course of the malady 
will clear the problem as well as the anatomical relations of zoster which 
are not presented by eczema. Herpes occurring after arsenic and 
carbonic oxid gas poisoning and herpes associated with pneumonia, 
meningitis, malaria, and typhoid present identical changes in the 
ganglia, nerves, and skin. 1 In these forms the girdle distribution is 
not pronounced, and the skin eruption tends to be symmetrical, though 
typical zoster may be encountered in these associations. 

Herpes simplex, affecting the lips and nose in coryza and gastro- 
intestinal intoxications, and herpes genitalis are still unclassified as to 
the participation of the root ganglia. 

Treatment. — The treatment seems comparatively unimportant. An 
antiseptic local dressing, preferably a dry one, a free action of the 
bowels, and the elimination of any discoverable toxic or infectious 
element are the indications. If the pain or burning sensation is severe 
a one per cent, cocain ointment will give relief. 

1 Howard, "Amer. Jour. Med. Sciences," Feb., 1903. 




-Herpes zoster confined to the fifth and 
sixth dorsal cord segments. 



PART V. 

DISEASES OF THE CORD PROPER. 



CHAPTER I. 
LOCALIZATION. 



Anatomical Considerations. — The spinal cord reaches from the 
foramen magnum to the lower border of the body of the first lumbar 
vertebra. From its lower portion the lumbar and sacral nerve-roots 
extend to their several intervertebral foramina and make up the cauda 
equina, which occupies the dural sheath from the lumbar enlargement 
of the cord to the bottom of the sacral canal. The relations of the 
cord to the surface of the body and to the vertebral bodies and the 
spinous processes are shown in figures 120 and 121. 

The cord is to be considered as made up of a number of similar and 
partly independent segments corresponding to the vertebral bodies, and 
each bearing a pair of spinal nerves. In addition it furnishes a longi- 
tudinal pathway for afferent and efferent nervous impulses. In early 
fetal life these cord-segments are in apposition with their corresponding 
vertebrae, but become gradually displaced upward as the spinal column 
outgrows the cord. At birth the lower end of the cord is opposite the 
third lumbar body. The nerve-roots, as a result of the unequal verti- 
cal growth of the cord and spine, become progressively longer from top 
to bottom, and in the same way the spinal-cord segment occupies a posi- 
tion relatively higher than its vertebral centrum. In the cervical region 
this amounts to the height of about one vertebral body, and in the dor- 
sal region to about one and a half vertebral bodies. The five lumbar, 
five sacral, and one or two coccygeal segments are crowded into the lum- 
bar enlargement below the upper level of the eleventh dorsal and above 
the second lumbar vertebral body. 

In estimating the position of the various vertebral bodies we are 
guided by the subcutaneous tips of the spinous processes. It will be 
recalled that these have a downward direction in the cervical and dorsal 
region and overlap the body of the vertebra below. Thus the tip of 
the eighth dorsal spine is on a level with the ninth dorsal body. Refer- 
ence to figure 121 will make this clear. It follows that the exit of the 
spinal root at the intervertebral foramen has only a relative relation to 

340 



LOCALIZATION. 



341 



the cord-segment from which it originates. Cord-lesions, are, therefore, 
always above the level of their spinal-nerve 
symptoms. 

Every spinal-cord segment possesses motor, 
sensory, and reflex functions besides vasomotor, 
visceral, and trophic activities. These are re- 
lated to corresponding body-segments, which 
are shown in their cutaneous extent in figures 
17 and 20. Their relation to the viscera has 
already been indicated (see p. 58). 



9l 



P 



? \3<C 



<$ 




\iX 



3,« 



ri! 






Fig. 121.— Showing the relation of the spinal cord to the body 
surface 



r-') 



Fig. 120. — The numerals in- 
dicate the relations of the verte- 
bral bodies and spines to the 
corresponding spinal segments 
of the cord. 



Cross-sections of the cord show that the 
gray and white matter vary in proportionate 
area and outline at different levels (Fig. 123). 
The white matter is divided into numerous 
zones and tracts. One division is based on 
the embrvological development of the various 
tracts (Fig. 124). From dissections, physio- 
logical experiments, and especially from the 
results of morbid processes, we have still further 
division of the tracts. These are shown in 



342 



DISEASES OF THE CORD PROPER. 



figure 125 for the ascending degenerations which follow complete divi- 
sion of the cord, and for the descending degenerations after similar lesions. 

The H -shaped cross-section of the gray matter shows numerous cell- 
bodies. Of these the anterior cornual groups are the best understood 
and contain the cell-bodies of the lower motor neuron through which 
motor, trophic, and vasomotor influences are exercised over the muscles, 
bones, and skin. The central canal is situated in the gray commissure. 
The essential elements of the cord are supported by fibrous tissue which 
is continuous with the penetrating septa of the pia mater. 

The circulation in the cord is one of its most important anatomical 
features. Many of the cord diseases are due to vascular lesions or 
infections, and both their vertical distribution and lateral outlines in 
transverse sections mav be limited to the corresponding arterial fields. 



'olumn eflissauer 




Fig. 122. — Cross-section of cervical spinal cord, showing its anatomical subdivisions (Schaefer). 



The arterial supply of the cord consists of two systems, anterior and 
posterior. The anterior spinal artery, arising within the skull by two 
roots from the vertebrals, extends the entire length of the cord at the 
anterior fissure (Fig. 127). It is reinforced by branches from the inter- 
costal, lumbar, and sacral arteries, which follow the corresponding nerves 
into the spinal canal and accompany the nerve-roots to the cord. The 
anterior spinal artery gives off about three hundred branches, called 
anterior median arteries, which penetrate the anterior fissure at a right 
angle to the parent stem. At the commissure they enter the cord and 
without dividing turn toward the right or left anterior horn. At the 
neck of the horn the artery divides into an anterior branch to the 
anterior horn and a posterior branch which is distributed to the neck 
and to a portion of the posterior horn. A branch is also given off in a 



LOCALIZATION. 



343 




C 1 



C 8 



L 1 






C 2 



D 1 



L 3 






C 4 



D 2 



L 5 






C 5 



D 5 



Sac 2 






C 6 



D 8 



Sac 4 




C 7 




D 12 




Co 



Fig. 123. — Transverse sections of the cord at various levels, to show the relative variations in gray and 

white matter. 




Fig. 124. — Divisions of the cross-section of the cord based on Flechsig's study of their development. 
A, Direct pyramidal tract ; B, fundamental fasciculus of the anterior column ; C, rest of lateral column. 
D, direct cerebellar tract ; E, crossed pyramidal tract ; F, lateral limiting zone ; G, anterior root zone ; 
H, middle root zone; /, median zone; J, column of Goll ; K, postero-internal root zone; L, postero- 
external root zone or zone of Lissauer (Marie). 




Fig. 125. — Scheme showing secondary degenerations. Ascending degenerations : 1, Fibers of the 
lding sulcomarginal fasciculus; 5, Gowers, tract ; 7, direct cerebellar tract; 8, eornucommissural 
tract ; 9, column of Burdach ; 10, the external root zone tract ; 11, zone of Lissauer ; 12, column of Goil, 
Descending degenerations: 2, Descending sulcomarginal tract; 3, direct pyramidal tract; C, crossed 
pyramidal tract ; 13, comma-shaped tract of Schultze (Marie). 

344 




345 



Fig. 126.— 1, Section of the cord shoeing division into three arterial districts (diagrammatic). Part 
supplied only by the anterior median and its branches is shaded with parallel lines. Part supplied only 
by the peripheral arteries is shaded with dots. Part supplied by both systems of arteries is unshaded. 
2, Transverse section of cord showing distribution of anterior and posterior arteries (modified after 
Marie). Part supplied by posterior arterial system shaded with dots. Part supplied by anterior system 
unshaded (Williamson). 

AS 




Fig. 127.— Arteries of the spinal cord. A S, Anterior spinal ; A M, anterior median; cc, commis- 
sural ; a a, anastomotic ; a e, anterior central ; p, posterior central ; a r, anterior root arteries ; a I, anterior 
lateral ; m 1, median lateral ; p I, posterior lateral ; p r, posterior root artery ; p c, posterior cornual ; p i, 
intermediate septal; p m, posterior median (modified after Obersteiner). 



346 



DISEASES OF THE CORD PROPER. 



vertical direction communicating with the next similar artery, and forming 
a longitudinal chain in the gray matter (Fig. 128). The anterior spinal 
artery, from its lateral ramifications on the surface of the cord, also sup- 
plies the white matter in the periphery of the ventral half of the cord. 
The posterior arterial system of the cord supplies its dorsal half. 
The two posterior spinal arteries arise separately from the vertebrals 
and, coursing around the medulla, extend the entire length of the 
cord just outside the posterior nerve-roots. Like the anterior spinal 
artery, they receive numerous supply branches from the intercostal 
and lumbar arteries. They give off anastomotic branches which unite 

with those of the anterior system 
on the surface of the cord, and also 
| present a chain of anastomosing 

jJslk branches on the posterior median line 

Jj ^^l of the cord. From these branches 

/^F^^ ^^jt\ small twigs penetrate the cord supply- 

\ jf I ing the gray matter of a portion of the 

posterior horn and the posterior half of 
the white matter of the cord (Figs. 127 
and 128). The arterial twigs entering 
the cord are of the terminal variety, 
and therefore do not anastomose. The 
territories of the two systems are not 
entirely independent, as the borders 
of their irrigation fields overlap and 
the adjacent white and gray matter 
receive arteries from both sources. 
Three arterial districts are thus con- 
stituted : (1) That supplied only by 
the anterior system ; (2) that supplied 
only by the posterior system, and (3) 
that irrigated by both systems (Fig. 
126). 

It will be apparent from these facts 
that arterial disease may induce lesions 
in the posterior half of the cord, or in 
the anterior half. Further, the in- 
fection or obliteration of a single an- 
terior median artery will practically 
destroy the corresponding anterior horn. 
The circulation in the cord, as a whole, presents some mechanical 
conditions that are significant. The spinal arteries are the longest of 
their size in the body, and, owing to their course, are not subject to the 
direct impact of cardiac impulses. In this respect they are very differ- 
ent from those of the brain. Arterial pressure is also slight, and the 
venous outlet into the plexuses about the dura is not an advantageous 
one in the erect position. Gravity impedes the return circulation as 
well as the supply. This is most marked at the lower end of the cord. 
The long course the lumbar and sacral arteries have to pursue in an 




Fig. 128. — Scheme to show circulation 
in cord segments and in vertical directions 
(Brissaud). 



LOCALIZATION. 347 

upward direction along the corresponding nerve-roots in the cauda still 
further reduces the circulatory qualifications of this end of the cord. 

The arteries in the cord are provided with perivascular lymph- 
sheaths, which are continuous with the arachnoid meningeal spaces. 
Vense comitantes accompany the arterial branches and empty into 
posterior and anterior plexiform venous chains on the surface of the 
cord, discharging in turn into the extradural plexuses. Regurgitation 
from the extradural veins is probably impossible. 

The posterior roots bear a ganglionic enlargement situated just out- 
side the dura, except on the lowest pairs, where it is within the sheath. 
Its function is trophic for the afferent tracts in the cord. 

Vertical Localization of a Cord-lesion. — Cord-lesions are irrita- 
tive or destructive and are manifested by corresponding symptoms in the 
periphery to which the injured cord-segments are anatomically related 
and to which their peripheral nerves are distributed. Irritative lesions 
are marked by sensory exaggeration, such as hyperesthesia and pain, by 
cramps and increased reflexes. Anesthesia, paralysis, and abolished 
reflexes result from destruction of a cord-segment. Trophic loss and 
vasomotor paralysis may also ensue, but become apparent at a later date. 
The symptoms of a cord-lesion embrace: (1) Those due to the derangement 
of the injured segment ; (2) those resulting from disturbances in the con- 
duction attributes of the cord, and (3) those arising from the secondary 
degenerations in the cord. These are variously combined, depending 
upon the extent of the lesion in the cross-section of the cord and its age. 

Motor Symptoms. — A completely disabling injury falling upon any 
cord-segment produces paralysis in the muscles supplied by that segment. 
It will be noticed, in the following table, that muscular actions are func- 
tionally grouped in the cord and extend in a vertical direction through 
several segments. Single muscles are, therefore, practically never alone 
paralyzed by spinal lesions. Such a circumscribed palsy, or one confined 
to a group of muscles supplied by a single nerve-trunk, at once declares 
the peripheral character of the lesion. Xot only are the muscles sup- 
plied by the injured segment paralyzed, but all muscles represented in the 
cord below the lesion are withdrawn from voluntary control through the 
division of their motor paths in the upper neurons, which traverse the 
cross-lesion by way of the pyramidal tracts. A paraplegia is thus induced. 

If the lesion is not a destructive one, but irritative in its effects, 
spasms and rigidity may be present. These are usually attended by 
clonus in the large muscles whose tendons pass over joints ; they are 
present in all the levels below the upper limit of the lesion, but more 
especially in the lower limbs. 

In late cases of partial cross-lesions the rigidity and spastic features 
are well developed. The lower limbs are held rigidly extended or, less 
frequently, sharply flexed. Any attempt to move them causes clonic 
trembling, which may finally end in a sharp pulling up of the leg with 
a " jack-knife "-like jerk, or the thighs may be held so rigidly by the 
muscles of the pelvic girdle that if one limb is raised from the bed 
by the foot the other follows with it. Contractures finally develop : 
(1) By the paralysis of one group of muscles and the unopposed over- 



348 



DISEASES OF THE CORD PROPER. 



action of antagonists ; or (2) by the overirritation of the motor mechanism 
of certain muscles or muscle-groups ; or (3) by structural changes in the 
muscles, causing a tendinofibrosis, with its characteristic retraction. Only 
when dealing with the third form is tenotomy permanently useful, as 
in the other varieties the activity of the muscular masses promptly re- 
produces the conditions sought to be relieved. In the structural variety 
the distorted joint usually has a certain limited range of free motion, 
but is then abruptly stopped by the retracted, unyielding tendons, which 
stand out prominently. On the other hand, the muscular contractures, due 
to overstimulation in which fibroid changes have not taken place, usually 
yield slowly or, perhaps, jerkily to efforts tending to extend them. 

Motor and Reflex Functions of the Spinal-cord Segments 
(after Starr and Edinger). 



Segment. 



Muscles. 



Reflexes. 



Cervical 
2-3 



r 
4^ r 

5 H 



6^ 



7 -! 
I 



Dorsal 1 I \ 

2-12 
Lumbar f 

1 ft 
I 



Sacral 
1-2 

3-5 



Sternomastoid. 

Trapezius. 

Scaleni. 

Small rotators of head. 

Diaphragm. 

Lev. ang. scap. 

Rhomboids. 

Spinati. 

Deltoid. 

Supiuat. long. 

Biceps. 

Supinat. brev. 

Serrat. mag. 

Pectoralis (clav.) 

Teres minor. 

Pronators. 

Brachialis ant. 

Triceps. 

Long exteusors of wrist and 

fingers. 
Pectoralis (costal). 
Latiss. dorsi. 
Teres maj. 

Long flexors, wrist and fingers. 
Extensors of thumb. 
Intrinsic hand-muscles. 
Dorsal and abdominal muscles. 
Abdominal muscles. 
Iliacus. 
Psoas. 
Sartorius. 
Flexors of knee. 
Quad, femoris. 
Int. rotators of thigh. 
Adductors of thigh. 
Abductors of thigh. 
Tibialis ant. 
Calf-muscles. 
Ex. rotators of thigh. 
Extensors of toes. 
Peronei. 

Long flex, of toes. 
Intrinsic foot-mnscles. 
Perineal muscles. 



Dilatation of pupil by irritating side 
of neck, 4-7 cervical. 



Scapular reflexes, 5 C-l D. 
Supinat. long., 5 C. 



Biceps, 5-6 C. 
Posterior wrist, 6-8 C. 

Anterior wrist, 7-8 C. 

Palmar, 7 C-l D. 

Epigastric, 4-7 D. 

Abdominal, 7-11 D. 

Cremaster, 1-3 L. 

Patellar, 2-4 L. 
Bladder, 2-4 L. 

Rectal, 4 L.-2 S. 
Gluteal, 4-. 5 L. 

Achilles, .5 L. 
Plantar, 1-2 S. 



Anal, 
Virile, 



3-5 S. 



LOCALIZATION. 349 

Sensory Symptoms. — A cross-lesion destroys cutaneous sensation in 
the segmental area corresponding to the lesion and in all parts below, 
the first directly, the second by interruption of conduction. The dis- 
tribution of anesthesia is practically the best guide to the upper level of 
the lesion. In the diagrams shown on pages 56 and 59 it will be seen 
that the cutaneous areas of the skin do not correspond exactly to the 
cutaneous distribution of the spinal nerves. This variation will often 
serve to differentiate between a cord-lesion and one of the nerve-roots. 
Root-lesions cause areas of sensory disturbances that coincide with the 
cutaneous distribution of the nerves arising from them. In the trunk, 
for instance, division of the cord produces an anesthesia whose upper 
level is practically in a horizontal plane, while root-lesion anesthesia or 
hyperalgesia follows the intercostal nerves and spaces. The territories 
supplied by the intercostal nerves overlap decidedly, so that destruction 
of a single nerve may manifest no sensory loss. It requires that at least 
two should be divided to produce an anesthetic patch or belt. 

The upper border of a spinal lesion is usually further indicated by a 
zone of hyperesthesia due to the irritant action of the lesion on sensory 
paths within the cord or upon the posterior nerve-roots. This is described 
by the patient as a band or girdle-like sensation about the trunk and as 
tightness in the limbs. Its vertical extent corresponds to the irritating 
influence, but rarely does it exceed two segmental areas. A light touch 
in this hypersensitive zone causes a feeling as of pins and needles, of 
pricking, of burning, of tingling, or of a thrill, and is not a pure exaggera- 
tion of sensation, but a perversion of it. Very severe pain is usually 
absent in pure cord lesions, but the girdling sensation is often described as 
painful ; and if the posterior roots are injured, as in Pott's disease or 
through meningeal inflammation, the pains are intense, and often darting 
in character. Spontaneous sensations are frequent, and patients often 
attempt to describe peculiar feelings of an unnatural sort which they 
may locate in areas that are absolutely insensitive to external stimulation. 
They may be caused by the irritation of the conduction tracts at the 
upper level of the lesion, and are then referred to the peripheral sites 
from which they would naturally arise. 

In lesions of lesser degree sensation may not be much affected, even 
when motion is abolished, or the general sense of touch may be broken up 
so that temperature and painful impressions are not recognized. Tactile 
impressions, in the same way, may fail to arouse the sensorium when more 
energetic and painful impressions still traverse the injured pathways. 

The reflexes furnish very valuable evidence not only as. to the 
upper level of the cord lesion, but sometimes as to its vertical extent. 
The cord lesion that destroys the portion of a reflex arc within the cord 
obliterates that reflex but does not abolish the reflexes below its own level 
unless the cord is entirely and completely divided. It is now fairly well 
established that complete division of the cord in man extinguishes all cord 
reflexes below that level. 1 On the contrary, if the division is incom- 
plete, the lower reflexes may at first be enfeebled, but within a few weeks 
show much exaggeration. In a case showing such increased reflexes the 
absence of one or more at a given level points to the diseased portion of 
Collier, "Brain," Spring, 1904. 



350 DISEASES OF THE CORD PROPER. 

the cord. Again, the upper level of abolished reflexes usually coincides 
with that of anesthesia, and both focalize the lesion. In other cases the 
extension and invasion of cord disease may be traced by the successive 
disappearance of spinal reflexes ; its recession, by their reappearance. 

Trophic Conditions. — As the trophic centers for muscles correspond 
with their motor spinal centers in the anterior horns, a lesion which 
destroys this portion of the gray matter of a cord's segment induces atrophy 
in the related muscles. This atrophy, like the palsy arising from a 
cord lesion, has a functional distribution that depends upon the associa- 
tion of muscular representation in the cord. By reference to the table, 
page 348, it is evident that all of a large muscle need not be involved, 
and that groups of muscles innervated by different nerve trunks, but 
centrally associated, may be thus selected. The extent of the wasting 
is limited by the vertical dimensions of the lesion. The muscles inner- 
vated from the cord above and below the destructive process are spared, 
and retain their nutritional supply and their electrical responses. 
The wasted muscles lose tone early, and shortly thereafter present the 
electrical reaction of degeneration. Atrophic loss is best seen in the 
muscles of the extremities ; next in those of the shoulder and j)elvic gir- 
dles. In the thoracic and abdominal regions the wasting is only per- 
ceptible when several adjacent cord segments are diseased. 

Slight atrophic disturbances appear in the skin, analogous to those in 
neuritis and confined to the area related to the injured cord segments. 
In the case of irritative lesions, such as acute myelitis and cord hemor- 
rhage, the dystrophic condition may be acute and intense. Under the 
incitement of comparatively slight pressure or other superficial irrita- 
tion, herpetoid eruptions and acute bedsores form in a few hours. 
These occur over the sacrum, heels, malleoli, and trochanters by 
preference, but may occur wherever the bones are subcutaneous and 
the trophic control disturbed. The use of counterirritation in the mild- 
est form, and even of frictions with the hand, may provoke them. Hot 
bottles that would otherwise cause no injury may, under these circum- 
stances, induce most serious local effects and deep destruction of tissue. 

Vasomotor disturbance in some degree is usually present, and 
consists, ordinarily, at first of a tendency to vascular dilatation and 
increased warmth. The so-called tache cerebrale is easily provoked 
below the lesion. In cases of long standing the skin is livid and cold, 
frequently with increased perspiration. Lesions in the cervical region 
often cause flushing and perspiration on the side of the neck and face, 
and may reduce the heart-beats to forty or even to twenty a minute. 
Dorsal lesions, on the other hand, are sometimes attended by a persist- 
ently rapid pulse. These vasomotor disturbances are frequently at- 
tended by an increase of body temperature in lesions in the upper 
dorsal and lower cervical regions, but it is often difficult to exclude 
pyrexia, due to the infectious nature of the disease or to intestinal or 
vesical disturbance resulting from it. 

Visceral symptoms are usually not pronounced, but the secretions in 
the alimentary canal and its muscular activity are frequently disturbed. 
Constipation is the rule, and fermentation of the stomach and intestinal 
contents, with gaseous disturbance and great abdominal distention, is very 



LOCALIZATION. 351 

common. Vomiting and difficulty in swallowing occur in lesions of the 
cervical cord. The anal and vesical sphincters are usually disturbed. 
"When the lesion involves their reflex centers in the lumbar cord, complete 
relaxation and incontinence ensue ; but if the lesion is above their spinal 
centers, voluntary control alone is lost. They then act automatically, 
and the corresponding viscera are unconsciously evacuated at intervals. 
The examining finger readily provokes the anal sphincteric contraction 
in this condition, which is not the case if its center is destroyed. 
There is a tendency to fecal and urinary retention, dependent, in part, 
upon the lack of power in the abdominal muscles. In the case of the 
bladder this leads to distention by increased residuum and weakening 
of the detrusor, and the dilatation of the viscus may become extreme. 
The result is usually a cystitis, which is often precipitated by the use 
of a septic catheter. Damage to the kidneys arises both from the 
back-pressure of urine and the propagation of inflammation up the 
ureters. The table of symptoms in disabling but not absolutely destruc- 
tive transverse cord lesions (see pages 353-359) is based upon the 
exhaustive work of Wichman. 1 If the entire cross-section is absolutely 
destroyed, the symptomatology is the same excepting that there is com- 
plete absence of muscle reflexes below the lesion. 

Horizontal Localization of a Cord Lesion. — Many spinal cord 
lesions are more or less circumscribed in transverse area, and give rise 
to widely different symptoms as they affect the various physiological 
divisions of the cord. Some cord diseases are symmetrical, and both 
sides of the transverse section show identical conditions. Others are 
unilateral, and the two sides show different states, not only at the level 
of the lesion, but also in the levels affected by the secondary ascending 
and descending degenerations. 

Lesions of the pyramided tracts produce motor paralysis below the 
level affected and induce a spastic condition in the paralyzed area, 
marked by increased muscle tonus, exaggerated reflexes, rigidity, and 
contractures. These tracts degenerate downward. 

Disease of the posterior columns is marked by sensory disturbance, 
especially of those elements of touch related to pressure and to the 
muscle and joint sensations. Ataxia results. The temperature and 
pain sensations are also usually diminished, and all forms of cutaneous 
impressions are delayed in reaching the brain. The muscle reflexes, 
especially the deep tendon reflexes, are abolished or greatly diminished. 
An upward degeneration in the postero-internal column ensues. 

When the anterior horn is affected motor paralysis occurs, but only 
in the muscles which are supplied by the large cells actually involved 
in the morbid focus. The mucles also atrophy. If the process is 
acute, paralysis takes place at once and atrophy gradually develops. In 
very insidious lesions paresis and atrophy develop at an equal pace, and 
fibrillary twitehings are usually present. Reflexes are abolished by 
lesions of the anterior horns and vasomotor paralysis is induced in the 
field related to the cornual disease. Defeneration descends the lower 
neurons arising from the diseased portion of the cord, and the reaction 
of degeneration is presented in nerve and muscle. 

1 "Die Ruckenmarksnerven und ihre Segmentbezuge, " Berlin, 1900. 



352 



DISEASES OF THE CORD PROPER. 



Disease of the posterior horn is marked by sensory disturbance or anes- 
thesia in a given area, such as follows a lesion of the posterior column. 

Lesions of the posterior roots cause anesthesia if complete ; hyperal- 
gesia and radiating pain if irritative. 

Lesions of the anterior roots produce the same results as lesions of 
the anterior horns. 

Lesions arising within or immediately about the central canal, as in 
syringomyelia, produce a peculiar dissociation of touch sensations, so 
that painful and thermal impressions are not properly recognized while 
tactile or contact impressions remain practically unaffected. Joint 
dystrophies are often added. 

A lesion that divides one lateral half of the cord gives rise to the 
Brown-Sequard syndrome (see p. 56). 

In many cord diseases two or more physiological divisions are sym- 
metrically affected. In amyotrophic lateral sclerosis we have, added to 
the rigidity, myotatic irritability, and contractures that mark disease of 
the lateral tracts, a progressive muscular atrophy that is due to the 
lesion of the anterior horns. Ataxic paraplegia is marked by symp- 
toms in both the lateral tracts and the posterior columns, and we find 
ataxia and rigidity with weakness variously combined. The following 
table roughly shows the relation of the various cord diseases to the physi- 
ological division of the cord. Those which are marked by lesions con- 
fined principally to given tracts in the spinal cord are denominated 
system diseases, as distinguished from indiscriminate lesions. As will 
appear in the consideration of individual diseases, some of these cord 
lesions, as in locomotor ataxia, are only a part of the morbid findings. 



( Indiscrimi- 
nate lesions. 



Organic dis- 
eases of 
the cord. 



System dis- 
eases. 



r Hemorrhage. 
Myelitis. 
Softening. 
Insular sclerosis. 
Tumors. 

Traumatic injury. 
Compression from bone disease and tumors. 



Lesions of 
single tracts. 



Combined 
lesions. 



Anterior cornu. 



Lateral tract. 



Posterior col- 
umns. 

Anterior cornu 
and lateral 
tract. 



Lateral and pos 
terior col- - 
umns. 



{Poliomyelitis acuta. 
Progressive muscu- 
lar atrophy. 

f Primary lateral 

sclerosis. 
I (Little's disease.) 
[ Lathyrism. 

J Locomotor ataxia. 
\ Ergotism. 

Amyotrophic lateral 
sclerosis. 



Ataxic paraplegia. 
Friedreich's ataxia. 
Heredocerebellar 

ataxia. 
Pellagra. 
Eesults of cross 

lesions. 















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360 



DISEASES OF THE CORD PROPER. 



Lesions of the Cauda Equina. — The descending roots of the 
lumbar, the sacral, and the coccygeal nerves make up the cauda, which 
occupies the dural sheath below the upper level of the second lumbar 
vertebra — a distance of about ten inches. As the roots are given off 
in lateral pairs, the upper ones are external and soonest pass into the 
vertebral foramina. Those that are longest, therefore, are situated 
toward the middle line. It is evident that a lesion involving the dural 
contents below the conus medullaris will produce a root lesion. This 
may be partial or complete, and varies according to the level which 
it occupies and the roots actually involved. The longer roots are 
usually most affected, even when the lesion is so placed as to embrace 
all the roots of the cauda extending below the conus. As a conse- 
quence, the nerves arising from the lowest cord segments and dis- 
tributed to the lowest body levels are 
the ones commonly disturbed. The paral- 
ysis, anesthesia, abolition of reflex action, 
and atrophy that result from a complete 
root division correspond to the peripheral 
distribution of the injured nerve roots. 
These peripheral distribution areas corre- 
spond somewhat to the segmental cord areas, 
but show a marked tendency to follow the 
distribution of the nerve trunks. (See Figs. 
15 and 16.) Both sides of the body are usu- 
ally affected, but uniform symmetry is the 
exception, while in cord lesions it is the rule. 
The lowest portion of the cord, known 
as the conus medullaris, comprises the third, 
fourth and fifth sacral, and the coccygeal 
segments. It contains the reflex centers 
for urination, defecation, ejaculation, and 
the anal sphincter. Lesions of the conus 
and the cauda present so many common 
points that the distinction is often very diffi- 
cult. After L. R. Miiller, Bruns, Cassirer, 
and others we may make the following differ- 
ential enumeration: 
The caudal lesion is: (1) Of slow onset except in traumatic cases. (2) 
It is attended by lancinating pains and painful paroxysms in the bladder, 
perineal, and sciatic regions. (3) Anesthesias embracing all modalities 
of sensation are of gradual and late development and rarely of accurately 
symmetrical distribution. (4) There is an absence of spasms, rigidity, 
fibrillation, and increased reflexes. The condition is one of flaccidity, 
the heel, plantar, and anal reflexes are diminished or abolished, the knee- 
jerk is retained, there is muscular wasting in the legs, and the reaction 
of degeneration in severe or advanced cases. (5) A gradually advancing 
paresis follows the sensory symptoms. (6) At the same time weakness 
of bladder, bowel, and sexual power develop. (7) There is frequently 
tenderness over the second lumbar spine and percussion tenderness over 




Fig. 129. — Area of anesthesia in 
a lesion of the cauda, affecting all 
the sacral roots. 



LOCALIZATION. 361 

the sacrum and lumbar region, where occasionally bony deformities 
can be detected by examination, the .r-ray, etc. (8) Remissions are 
frequent. 

The conns lesion is: (1) Usually of abrupt onset. (2) Pain is not a 
marked symptom and may be quite absent. (3) Anesthesias of perineal, 
gluteal, and pudendal regions are a common early symptom, of marked 
symmetrical distribution, and frequently of the dissociation type ; testic- 
ular sensitiveness is retained. (4) Motor irritation, such as fibrillations, 
cramps, and rigidities, are common, but the tendon reflexes in the lower 
extremities are not much modified. (5) There is early weakness of 
bladder and bowel control with sphincteric relaxation and loss of erec- 
tions. (6) Both motor and sensory features are of early appearance and 
advance in parallel; remissions are infrequent. 

The usual lesions which affect the cauda are vertebral fractures and 
dislocations, new growths, penetrating wounds, and hemorrhage. In 
tabes and multiple neuritis, which are sometimes confounded with 
caudal disease, symptoms are present at higher levels, as in the upper 
extremities and in the pupillary reflexes. Injury to the plexuses within 
the pelvis usually — at least, at first — produces unilateral symptoms. 



362 DISEASES OF THE CORD PROPER. 

CHAPTER II. 
INDISCRIMINATE CORD LESIONS, 

TRAUMATIC LESIONS OF THE CORD SUBSTANCE. 

The spinal cord is sometimes reached by penetrating wounds made 
by knife, bullet, or other foreign object. It is injured more frequently 
by the displacement of vertebrae, and this is almost invariably attended 
by fracture. With the surgical conditions we shall not deal. It is to be 
noted that vertebral fracture-dislocations are frequently devoid of any 
external signs of displacement, even when it is found postmortem that 
the vertebral bodies have been so completely displaced as to actually 
shear the cord in two. Restitution to a practically normal position 
may occur at once, either spontaneously or due to the lifting efforts 
of those who first attend the injured person. These cases all furnish a 
history of trauma, and usually present local evidence of it. The ques- 
tion that arises regards the location and extent of the lesion in the cord. 
This must be determined by an application of the considerations set 
forth in the foregoing chapter. 

The prognosis in a case of actual injury to the cord substance is 
always grave and generally fatal. If the lesion cause complete divi- 
sion, there can be no hope for voluntary control or sensory improvement 
below its level. Only in very slight injuries from dislocation of the 
vertebrae or from pressure due to meningeal hemorrhage can much be 
expected. In such a case complete paralysis may pass away ; but when 
the reflexes are completely abolished in the paraplegic area after the 
first week, little improvement need be expected. Some degree of dis- 
ability always persists, and commonly bedsores, cystitis, kidney and pul- 
monary complications carry off the patient after a lingering helplessness. 

HEMORRHAGE INTO THE CORD (HEMATOMYELIA). 

Hemorrhage into the spinal cord is not an extremely rare accident. 
It occurs under a variety of circumstances, and is punctate and multiple 
or single and more or less extensive. There is also a so-called perforat- 
ing form simply due to the tendency of the extravasated blood to follow 
the lines of least resistance in the longitudinal direction of the cord. 

Etiology. — Hemorrhage into the cord, like spinal meningeal hem- 
orrhage, with which it is frequently associated, may follow severe spinal 
concussions and violent wrenchings of the back. Excessive muscular 
effort, as in lifting, has caused it, and Gowers reports this accident 
following repeated coitus. A focus of myelitic softening is frequently 
the seat of hemorrhage, and hemorrhage, in turn, is followed by a zone 
of myehc softening. It is often difficult to tell which process was the 
initial one. In some cases of caisson disease, or divers' palsy, hemorrhage 
has been found due to the too sudden reduction of the high atmospheric 
pressure under which such work is done. Continued convulsions, as in 
status epilepticus, intense chorea, tetanus, and asphyxia, may produce 
punctate hemorrhages and hemorrhagic infiltration, especially in the 



INDISCRIMINATE COED LESIONS. 



363 




gray matter of the cord. Purpura and sudden cessation of habitual 
hemorrhages, such as that from piles and menstruation, may provoke a 
cord-apoplexy. A dilated central canal and teratological defects and 
fissures in the cord predispose to it. Changes in the arterial coats are 
much less active factors than in cerebral hemorrhagic apoplexy, as 
atheroma and miliary aneurysmal dilatations are of the greatest rarity 
in the cord. The arterial pressure conditions and the direct cardiac 
impulse that play so large a part in brain-lesions are also absent. 

Morbid Anatomy. — In the punctate and infiltrating variety the 
cord may merely appear slightly reddened, or small, pinhead clots may 
be found, particularly in the gray matter. They usually first occupy 
the perivascular spaces and, aside from traumatic cases, are secondary 
to myelitic softening. The appearance varies with the size of the extrava- 
sation. The large single or focal hemorrhage also finds its usual seat in 
the gray matter, less commonly in 
the central canal or in a congen- 
ital fissure of the cord. It is usu- 
ally ovoid in shape, with the long 
axis vertical, and may perforate 
the yielding gray substance of the 
cord for several inches in extreme 
cases. It causes a fusiform, dark- 
colored swelling of the cord. The 
blood usually comes from the 
larger median arteries or from 
those entering the anterior horn 
by the anterior roots, and favors 
the gray matter as a situation. 
In rare instances the blood may 
break through the white columns 
and even appear to a slight extent 
in the membranes. Meningeal 

clots are also commonly present in traumatic cases. Around the clot, after 
a few days, the cord shows a zone of softening. In cases of long standing 
the clot may undergo changes similar to those in the brain, and a hemor- 
rhagic cyst remains, with ascending and descending degenerations corre- 
sponding to the location of the lesion in the cross-section. A wide area of 
myelitis, containing a comparatively small and recent clot or hemorrhage 
into a gliomatous growth, may be encountered as secondary accidents. 

Symptoms. — A primary focal hemorrhage into the cord is of rapid, 
usually of sudden onset. The infiltration sort, being almost always sec- 
ondary, may be preceded by sensory and motor symptoms for hours, 
days, and even weeks. This is also true of the larger clot that forms 
in a softened myelitic territory, producing sudden exacerbation of the 
usually precedent paraplegic symptoms. The earliest symptom is com- 
monly one of severe pains radiating in the body -segments correspond- 
ing to the hemorrhagic focus. These are due, presumably, to the pressure 
or laceration of the sensory tracts in or near the posterior commissure. 
Darting pains occur in the limbs, girdling pains in the trunk that may 







Fig. 130. 



-Hemorrhage 
the cervical cord belov 



into the gray matter of 
the centers for the biceps, 
and supinator longus ; paralysis and atrophy of the 
triceps and extensors of wrists and fingers. 



364 DISEASES OF THE COED PROPER. 

be mistaken for angina pectoris and intestinal or vesical colic. Very 
shortly — that is, in the course of a few minutes or an hour — after an acci- 
dent has occurred, and the patient has perhaps walked a short distance, 
paraplegic symptoms appear. These may be partially unilateral at 
first. The legs weaken, the patient gradually or quickly sinks 
down, and usually the motor loss is promptly established at its 
maximum. The condition that now develops depends on the 
location, extent, and size of the clot, and the amount of pressure it 
brings to bear on the conduction tracts. Usually there is some im- 
provement, owing to the subsidence of the pressure and of the shock 
or insult to the adjacent portions of the cord. The development 
after a day or two of myelitic softening or myelitis, with elevation of 
the body-heat, usually again emphasizes the paraplegia, and thereafter 
the course of the disease and its treatment is that of myelitis. The 
bladder and anal sphincters are commonly immediately relaxed. All 
the tendon reflexes are diminished at first, but after a week or ten days 
they begin to increase, and comport themselves as in the spastic state 
that follows an incomplete cross-lesion of the cord. Early in the attack 
spasms and tonic convulsions in the muscles supplied by the affected 
segments and those below the lesion are frequently met with. 

The diagnosis is often difficult and it is frequently impossible to 
exclude a meningeal hemorrhage. Preceding sensory, motor, and tem- 
perature disturbances indicate a primary myelitis. Only in those cases 
where the temperature is normal, the onset abrupt, and the pain of the 
segmental variety, can a definite diagnosis be ventured. 

The prognosis depends upon the location of the lesion. Hemor- 
rhage into the cord in the upper cervical region is almost certainly 
fatal, and is worse in the cervical and lumbar enlargements than in the 
dorsal region. The secondary myelitis may extend upward and cause 
death, or downward and involve the lower levels. Only when sensa- 
tion improves, motor gain is apparent, and febrile disturbance is passed, 
is the patient safe. Some lasting local paralysis, wasting, and trophic 
disturbance result, and more or less permanent spasticity remains. Too 
often bedsore, cystitis, sepsis, or other complications carry off the patient. 

Treatment. — The immediate treatment of the hemorrhage consists 
of measures to check it. The patient should be placed face downward 
with the spine elevated as much as possible, and applications of ice or 
ice-bags made over the length of the cord. Absolute quiet and the 
determination of blood to the surface, intestinal tract, and extremities 
should be favored. The arterial tension may be reduced by minim doses 
of tincture of aconite or veratrum viride every hour, but the use of ergot 
is not advised. After the first day the treatment is that of myelitis. 

THROMBOTIC SOFTENING OF THE CORD, 
Thrombosis of the arteries of the spinal cord undoubtedly occurs fre- 
quently. The anatomical features of the circulation in the spinal cord ren- 
der this accident a very likely one. The long course the arterial supply 
traverses, especially in the lumbar cord, produces a sluggishness of its 
current that favors the deposition of fibrin if at the same time the 
arterial wall is nutritionally disturbed. As the spinal arteries after en- 



INDISCRIMINATE CORD LESIONS. 365 

tering the cord are of the terminal variety, it is evident that their oblit- 
eration will result in the softening of their irrigation fields. This result 
has ordinarily been confounded with myelitis and clinically presents the 
same picture. Gowers denies its occurrence, as does Striimpell, but in 
syphilitic cases this mechanism is demonstrated by such cases as are 
described by Williamson 1 and those of Schmaus, Sottas, Dejerine, and 
Knapp quoted by him. Lloyd 2 also refers to such an one in his own 
experience. Biernacki 3 reports three cases in full, two of which were 
syphilitic. Embolism, on the other hand, can practically be excluded, 
owing to the narrowness of the spinal vessels, the long and tortuous 
course they pursue, and the slowness of the blood-stream. Experiment- 
ally, however, by the injection of inert powders into the circulation of 
lower animals it has been produced by Lamy, 4 Singer, 5 and others. 
Though atheroma is infrequent in the spinal circulation, syphilitic cases 
commonly show eudo-arterial and peri-arterial changes. The same are 
likely to occur in infectious diseases and in many blood states, and 
favor thrombosis. 

The softened area resulting from thrombotic occlusion of the supply- 
ing artery, just as in the brain, is likely to become hemorrhagic through 
the venous back-pressure, and, therefore, may present any degree of 
hemic discoloration. Into it a neighboring blood-vessel may rupture, 
with hemorrhagic results. 

This condition, as Langdon 6 has well pointed out, comes on rather 
abruptly without prodromal malaise, fever, or infection. Commonly 
there is a tendency for the symptoms to increase often by sudden addi- 
tions and extensions. At first commonly unilateral, the condition tends 
to become bilateral and the sensory and motor defects symmetrical. 
The girdle sensation and impairment of the sphincters are less marked 
and later developed than in acute myelitis, and bedsores less likely 
to appear. Leukocytosis is wanting. The treatment should be to 
strengthen the general circulation and use those remedies which favor 
resolution of local exudates. Most of these cases are syphilitic and 
require iodid and mercury. In other respects the management and 
prognosis is the same as that of myelitis. 

MYELITIS. 

Under the term myelitis a host of spinal lesions have been grouped 
which have in common the appearance of a local softening, with more 
or less inflammatory disturbance. Inflammation of the cord-substance 
is probably never a primary process. Infection may readily reach the 
cord by the vascular supply. That it does so is evident in the inflam- 
matory lesions of the cord-substance that so often follow the exanthe- 
mata and septicemic diseases generally. 

The term myelitis is a generic one. In this chapter we are dealing 
with the indiscriminate lesions of the cord-substance, and, therefore, re- 
serve for separate consideration the variety of myelitis known as acute 

1 ' ' Relation of Diseases of the Spinal Cord to the Spinal Blood-vessels, ' ' London, 
1895. 2 "Nervous Diseases," by American Authors, Philadelphia, 1895. 

3 "Deut. Zeit. f. Nervenheilk.," Bd. x. 

* "Archives de Neurologic, " 1894. 5 "Deut. Zeit. f. Heilk.," Bd. xvii, 1897. 

6 l ' Jour. Nerv. and Mental Dis. 3 " April, 1905. 



366 DISEASES OF THE CORD PROPER. 

anterior poliomyelitis that singles out the anterior gray matter, is largely 
confined to it, and presents a distinct clinical type. We may distinguish 
a transverse myelitis, one that is disseminated, and a central form depend- 
ing merely upon the accidental location of the lesion or lesions in the 
cord. Of these, acute transverse myelitis may be taken as a type, and is 
the one commonly encountered. 

Etiology. — Acute myelitis may follow wounds of the cord, lacera- 
tions of its substance, from hemorrhage, or from fracture-dislocations of 
the vertebrae. It has followed violent muscular efforts, spinal concussions, 
and falls on the back, but in such cases minute myelitic hemorrhage or 
other structural lesion may have introduced the program. It has been 
repeatedly attributed to cold and exposure, and this assertion has been 
handed down so persistently that it seems a permanent fixture in the 
literature. If cold plays any part, it is, as in pneumonia, to favor the 
introduction of infection. Compression of the cord by disease of the 
spine or the meninges, or by new growths, causes a localized softening 
which may girdle the cord. The association of myelitis and menin- 
gitis is shown in the condition of meningomyelitis already described. 
The extension of the inflammatory process to the cord is a clearly recog- 
nized feature of most meningeal infections. It may follow all the acute 
infectious diseases ; probably by an initial thrombosis. Syphilis frequently 
leads to it, and usually by a thrombotic process. It may also result 
from a gummy tumor or from syphilitic meningitis. These will be 
considered more at length in the chapter on Syphilis of the Nervous 
System. Influenza, gonorrhea, all infectious and pyemic conditions, and 
caisson disease have caused it. 

Morbid Anatomy. — On inspection an inflamed cord presents a red, 
swollen appearance and a reduced consistency that may make it pulta- 
ceous and even diffluent. The vertical dimensions of the softening vary 
from one-half an inch to several inches, and usually embrace the full 
thickness of the cord. Depending upon the amount of extravasated 
blood and the age of the lesion, the myelitic portion is red, yellowish, or 
white. It is usually difficult or impossible to distinguish the gray from 
the white portions of the cross-section, and commonly the softening is so 
great that the cord breaks down under the slightest handling. All details 
are then obliterated. Microscopically, there is more or less disintegration 
of the cord-elements. There is usually present an abundance of phago- 
cytic elements, and amyloid bodies are frequently encountered. The axis- 
cylinders are destroyed, or divided or granular. Sometimes a few of 
them appear much swollen. The nerve-cells participate in the destruc- 
tion, and those that are recognizable appear swollen, pigmented, gran- 
ular, filled with fat-globules, or vacuolated. Their processes early dis- 
appear. The vessels are altered, their walls thickened ; the perivascular 
sheaths are dilated with cells, detritus, and hemorrhage. The intersti- 
tial tissue is exaggerated in proportion to the duration and intensity of 
the disease, and in the disseminated form of myelitis forms islets of 
thickened tissue. There are usually many spider-cells present. The 
meninges are variably affected by extension of the inflammation to them. 
In cases of long standing the cord may be reduced to a mere fibrous 
shred. 



INDISCRIMINATE CORD LESIONS. 367 

If the lesion has been of sufficient duration, ascending degenerations 
are found in the posterior and direct cerebellar columns, and descend- 
ing degeneration in the pyramidal tracts. In addition, by the process 
of contiguous extension the myelitis may propagate itself in either direc- 
tion from its initial focus along any of the tracts of the cord, or along 
its gray substance, irrespective of the direction of conduction in the 
physiological pathways. 

In disseminated myelitis small foci of inflammation are scattered 
throughout considerable portions of the cord, presenting the same mi- 
nute changes as outlined above. It may require the microscope to detect 
them, or they may be manifest as small red or hemorrhagic points in 
the cross-section. In the central form there is cellular infiltration about 
the central canal, which is often dilated and choked. The nerve-roots 
arising from the focus of inflammation show neuritic changes and de- 
generation, with corresponding muscle changes. Should a myelitis be 
infectious from the first, or subsequently infected by pus-producing bac- 
teria, abscess formation results. From such a cord-abscess the menin- 
ges may become infected and a purulent meningitis ensue. 

Symptoms. — The symptoms of myelitis are as diverse as the cases, 
and each case varies with the vertical or transverse location of the 
lesion or lesions, with their number, extension, severity, and character. 
The onset is modified by the initial cause of the disease in the cord. 
When hemorrhage is the first step, it is apoplectic in suddenness. 
Traumatism has its own history. The infectious diseases have their 
individual clinical features upon which the myelitis is grafted. In less 
well-marked antecedent states the onset of the paraplegic features of the 
disease may be unheralded by any subjective or objective phenomena. 
A few days of malaise, of slight fever, or of fleeting paresthesia may 
indicate the systemic condition which eventuates in myelitis. In other 
but rare instances convulsions, high temperature, and rigors declare the 
toxic process and usher in the spinal symptoms. These consist usually 
at first of intense pains, which may be darting in character, extending along 
the limbs or girdling the trunk. There is more or less tingling and numb- 
ness. The distribution of such sensory disturbance in relation to the 
cord-segments should be significant. Shortly after — in a few minutes 
in hemorrhagic cases, in a few hours or a few days in infectious forms 
— more or less paraplegic weakness is developed, which involves every- 
thing below the segmental location of the disease. The motor loss 
may be sudden or gradual, complete or partial, but usually is insidi- 
ous, progressive, and does not reach an absolute degree. The control 
of bladder and bowels is usually disturbed early, with more or less 
incontinence or retention. In some instances the motor features come 
on and progress with the sensory disturbances, or even precede them. 
The order of symptoms depends upon the portion of the cord first and 
most diseased and the destructive or irritative character of the lesions. 
It follows that spasmodic twitching of the limbs may occur, but, as a 
rule, there is complete flaccidity at first. 

The number and variability of the symptoms are so great that they 
can best be presented under several heads. 



368 DISEASES OF THE CORD PROPER. 

Sensation. — The upper level of the sensory disturbance is usually 
marked by a hypersensitive band corresponding to the upper segmental 
extent of the cord-lesion, and due to its irritant action. This is always 
present in cross-myelitis, and should be diligently sought, as it is of the 
greatest localizing importance. In the entire area below the hyper- 
sensitive zone sensation is more or less blunted and may be completely 
lost in all its modes. When the cross-lesion is less complete, sensation 
or motion, or both, may be only partially involved. When the lesion 
is practically central, we have the peculiar dissociation of touch-sensa- 
tions that marks lesions in this location. There is analgesia and loss 
of temperature sense, with preservation of tactile perceptions. Involve- 
ment of the posterior roots and extension of the inflammation to the 
meninges are marked by local pain and tenderness over the spine at the 
level of the lesion and above it. The girdle pain has the same topo- 
graphical significance as the hypersensitive zone, and usually corresponds 
to it. The patient often complains of paresthetic sensations below the 
lesions, even in completely anesthetic territory, or in the abdominal 
viscera. These may be misleading to both patient and physician. The 
greatest care must be exercised in testing the cutaneous and other sense 
perceptions, as indicated in Part I. The sensory symptoms frequently 
vary greatly during an attack unless the lesion completely severs the 
cord. The reappearance of sensation where previously wanting is a 
good sign, just as the increase of sensory loss is indicative of extension 
of the disease and of bad import, sometimes of fatal significance if 
toward the upper cervical levels. 

Motion. — The loss of motion corresponds to the same segmental distri- 
bution as the anesthesia, and may be complete or partial. The anterior 
gray matter in the inflammatory focus is usually completely destroyed, 
or at least its functions are completely inhibited for the time. The mus- 
cles controlled by this portion of the cord are paralyzed. The amount 
and degree of paralysis below the lesion depend upon the completeness 
of the cross-lesion, and varies within wide limits. In the disseminated 
and multiple forms of inflammation various functionally related groups 
of muscles may be singled out, as in acute poliomyelitis. Here, also, 
the motor loss may show any degree of incompleteness. The loss of 
sphincter control is usually present from the first and persistent. When 
the lumbar cord is affected, incontinence of urine and distention of the 
bladder and bowels follow the destruction of their spinal centers. The 
distribution of the paralysis is, therefore, always dependent upon the seg- 
ment or segments of the cord that are diseased, and has a common ten- 
dency to paraplegic distribution, involving both sides more or less sym- 
metrically. The distribution of symptoms in rare instances suggests the 
Brown-Sequard syndrome, due to a lateral hemicordal division (see p. 56). 

Reflexes. — The reflexes whose spinal centers are situated in the 
inflammatory focus are abolished. Below that level they are usually 
diminished at first, but at the end of a week or ten days commence to 
increase in vigor and gradually attain extreme exaggeration. Should 
the lesion actually divide the cord, they are abolished, as in traumatic 
cases, but the preservation of a very few fibers in any portion of the 



INDISCRIMINATE CORD LESIONS. 369 

cord's cross-section seems sufficient to allow of their exaltation and the 
development of spasticity and rigidity. All forms of clonus and intensi- 
fication of reflex activity may be encountered. The tendency is for the 
lower limbs to be rigidly extended, adducted, and sometimes crossed. 
Less frequently flexion predominates and the legs are flexed upon the 
thighs, which are firmly applied along the anterior surface of the trunk. 
The clonic condition of the limbs sometimes serves to jerk them about 
sharply upon slight skin friction, even by the removal of the bedding 
or any gentle manipulation. The flaccidity of the early days is replaced 
by a hyper tonicity, so that the muscle-masses may stand out promi- 
nently. Contractures may result and often do. Priapism is commonly 
present in cervical myelitis, and frequent in inflammation of the dorsal 
cord, but absent in lumbar involvement. Lesions in the cervical region 
are commonly attended by a dilated pupil, but in some cases, especially 
of the disseminate variety, optic neuritis is present, and pupillary re- 
sponses are variously modified. The condition of the vesical and rectal 
reflexes is one that should early engage attention. If the lesion involves 
the lumbar cord, the sphincters are usually relaxed and incontinence fol- 
lows, but there is a tendency to urinary retention through relaxation of the 
visceral walls, and cystitis is easily established. Again, when the lesion 
is above the lumbar cord the sphincters operate automatically, and both 
feces and urine are discharged at intervals ; but, again, the bladder-wall 
is likely to yield, or acts ineffectually without the aid of the abdominal 
muscles ; urine is retained, becomes ammoniacal, and, through contami- 
nation by catheter or otherwise, cystitis develops. Rupture of the blad- 
der through distention and ulceration, causing peritonitis, has been seen. 
Some cases present a most obstinate and excessive gaseous intestinal 
distention. This occurs most frequently when the lesion is above the 
mid-dorsal region. 

Trophic Changes. — The muscles that are anatomically related to 
the diseased cord-segment waste promptly and show the reaction 
of degeneration. In addition the inert limbs lose in size from disuse 
and considerable emaciation is frequently presented, but the electrical 
changes are lacking and the reflexes are usually increased. The general 
vasomotor and trophic conditions below the lesion are disturbed. A slight 
stroke of the finger-nail upon the skin will usually present a line of 
persisting vascular stasis like the meningeal tache, and at first the 
paralyzed portions show an elevation of temperature even above that in 
the mouth. In cases of long standing the local temperature is abased 
and the paralytic members are blue, cold, cyanotic, and often edematous. 
The skin is often dry, harsh, and scaly, and readily breaks down under 
pressure, forming ugly, sluggish, unmanageable bedsores. The tend- 
ency to bedsore is prominent from the first, and it is in these cases that 
the sacrum is sometimes denuded within a few days under the continued 
influence of pressure, irritation from urine or feces, and the dvstrophic 
element. The entire vesical mucous lining may exfoliate from dis- 
turbed trophic conditions. Joint-lesions of the arthropathy sort are 
rarely induced. 

The general nutrition of the patient suffers to some degree, but less 
than would be expected, and it can usually be maintained at a reason- 

24 



370 DISEASES OF THE CORD PROPER. 

able level. The danger arises from extension of the myelitis and from 
complications arising through cystitis, bedsore, nephritis, and septicemia, 
or concurrent acute infections, such as pneumonia. 

Course. — Acute cases reach their maximum in a few days, others 
in a few weeks, and then, if death does not result, a long stationary 
period or one of gradual improvement or decline succeeds. The occur- 
rence of an extension of the inflammation may, at any time, jeopardize 
life by invading the respiratory apparatus. Acute bedsore is always a 
dangerous complication, and cystitis is hardly less so. When spastic 
features develop, they rarely recede to any considerable extent, and imply 
permanent disability and the paraplegic state. Sensation or motion may 
return singly. The localized wasting due to involvement of the anterior 
gray never repairs, and adjacent portions of the gray matter may subse- 
quently be involved. Death may take place early from cardiac and 




Fig. 131. — Dystrophic bedsores over trochanters and sacrum in a case of transverse myelitis. 

respiratory failure or follow at any period from exhaustion due to the 
primary infection or that secondary to bedsore, cystitis, nephritis, septi- 
cemia, or is caused by a gradual extinction of the vital energy. The cases 
that recover bear the indelible marks of the disease in weakened and 
spastic legs, areas of anesthesia, sphincteric paresis, and local atrophies 
variously distributed in accordance with the seat, extent, and intensity 
of the cord-injury. These furnish cases of so-called chronic myelitis, 
but inflammation has subsided and the conditions presented are due to 
the degenerations that follow the primary lesion. They are more fully 
described under the head of The Paraplegic State. 

Diagnosis in myelitis presents numerous problems and requires 
painstaking examination and study. We have to ask ourselves : (1) 
Whether the corcl is actually diseased ; (2) the extent of that disease — 
namely, its localization — and (3) its origin. Unless there is loss of 



INDISCRIMINATE COED LESIONS. 371 

certain groups of cord- functions anatomically related, we can not incrimi- 
nate the cord. Of these, the most important are early loss of motion of a 
paraplegic distribution and relaxation of the sphincters. Corresponding 
sensory disturbance or anesthesia surmounted by a band of hyperes- 
thesia will almost surely be added to, if it does not precede, the motor 
loss. The onset is usually acute, and in the hemorrhagic variety it is 
sudden. Extreme pain of a radiating, segmental variety and sudden 
onset suggest an initial vascular lesion. After ten days we may detect 
muscular atrophy corresponding to the lesion and usually increased 
reflexes below the lesion, which usher in the spastic stage that is to per- 
sist as a paraplegic state if the patient survives. Even before this time 
the loss of faradic response in the muscles innervated by the spinal gray 
embraced in the inflammatory focus may indicate the myelitis and its 
vertical extent. To the further localization of the cord disease we bring 
to bear the considerations set forth in the preceding chapter. Our main 
early guide is loss of reflexes and the vertical extent of such hiatus in 
the chain of spinal reflexes. 

In poliomyelitis sensory deficiency is not present and the motor loss 
is usually of monoplegic outline. In meningitis Ave have the early and 
persistent root pain, tenderness over the spine, and retention of motion 
and reflexes. In Landry's palsy, or acute ascending myelitis, we meet 
the steady advance of the paraplegia from the feet and legs upward, 
with undisturbed sensation, faradic activity, sphincteric control, and 
tendon reflexes. In multiple neuritis the slow onset, involvement of all 
four extremities, major affection of the extensors, and paresthesia? at 
the distal ends of the limbs are significant. In hysteria the sensory 
disturbance has a characteristic outline, the reflexes are not greatly dis- 
turbed, trophic changes are not present, and hysterical stigmata are ob- 
tainable. The mistake usually made is to overlook an organic disease 
because hysteria is also present. 

The diagnosis of myelitis having been reached, it is always in order 
to question its origin. This may be evident from the history or 
presence of traumatism, acute infectious disease, septicemia, syphilis, or 
other cachectic state. 

Prognosis in such a generic condition as myelitis must be based 
upon general rules applied to the individual case. The outlook is 
always grave as to life and positively bad as to complete recovery. If 
the patient is not carried off during the first few days by the implication 
of the cardiorespiratory apparatus, or by the overwhelming systemic 
effect of the infection, which is perhaps only locally manifest in the cord, 
and if he reaches the end of the first week without any indications of 
extension of the myelitis, he may be considered out of immediate danger* 
If at the end of three or four weeks he does not show at least some 
slight return of motion and sensation, it is not likely that these will 
ever greatly improve. On the other hand, distinct improvement within 
the first two or three weeks is usually followed by rapidly progressive 
gain almost to the point of entire recovery. AVhen spasticity appears 
it implies descending degeneration in the pyramidal tracts and lasting 
disability. Cervical myelitis is almost invariably fatal. Involvement 



372 DISEASES OF THE CORD PROPER. 

of the dorsal cord is much less disastrous than when the lesion invades 
the lumbar enlargement and perforce permanently cripples the sphincter 
control and the legs. Acute bedsore and acute cystitis are ominous 
complications. Local muscular atrophies are subject to this rule : If 
faradic response can not be obtained in such muscles at the end of the 
first two weeks, they may be considered as permanently impaired. In 
syphilitic cases that reach a marked degree of paralysis we may hope 
to prevent extension of the disease and sometimes to secure a marked 
recession of the paresis but never for complete cure. 

Treatment divides itself into three parts : (1) That of the causal 
condition ; (2) that of the invasion stage, and (3) that of the paraplegic 
state. Traumatic conditions, pressure from meningeal hemorrhage or 
new growths require surgical measures. Any systemic infection or 
infection atrium must be directly dealt with. For the local condition 
the treatment outlined for meningitis is available. During the invasion 
period the inflamed cord should be kept elevated by placing the patient 
in the prone posture. Local applications of ice are useful. Active 
cathartics should be used if the patient's strength warrant their admin- 
istration. Quiet, and above all cleanliness, must be secured and local 
pressure avoided. Early attention to the bladder is usually needed but 
catheterization is only indicated when vesical retention can be determined 
by palpation and percussion, and then must be carried out with the most 
scrupulous antiseptic precautions. Febrile disturbance is usually a 
part of the original causal process and to be met accordingly. 

After the first two or three days, if the case runs on, a water or air 
bed will be found of the greatest service in distributing pressure. The 
heels, elbows, and other bony prominences in the paralytic field should 
be carefully padded with cotton. The constant use of a bed urinal 
will often help to keep the patient dry. Alimentation and sup- 
porting treatment will require thoughtful attention. At the end of 
a week careful massage and faradization may be employed, if not 
contraindicated by surgical conditions in the spine. Gentle frictions 
and kneadings of the muscles are indeed advisable from the first day, 
and the position of the paralyzed limbs should be changed hourly if 
only slightly, as is automatically done in healthy sleep. When a bed- 
sore develops, its best management depends upon keeping it perfectly 
dry. To this end a soft gauze pad and an abundance of pulverized 
boric acid should be used, but the dressing must not be cumbersome or 
so arranged as to exercise pressure and the patient's position must also 
conform to this requirement. Cystitis requires careful, thorough, 
skilful catheterization and washing out of the bladder every eight or 
twelve hours. The administration of salol, beta-naphtol, or urotropin 
also tends to render the urine unirritating and to some extent disinfects 
the bowel contents. The management of the case now resolves itself 
into one of good nursing and attention to obviate complications, espe- 
cially malposition of joints and contracture deformities. 

As motion and power reappear the patient should be encouraged to 
use the limbs intelligently. By concentrating his attention upon a 
certain movement he can often produce it after a number of attempts. 



'INDISCRIMINATE CORD LESIONS. 373 

Local nutrition must be kept up by massage and electricity. The use of 
the faradic brush to the anesthetic area is of service in restoring sensation. 
The general physical condition and usual constipation require constant 
attention. 

THE PARAPLEGIC STATE. 

The paraplegic state is the usual termination of a myelitis or any in- 
discriminate cord lesion that does not end fatally, and corresponds in some 
sense to the " hemiplegic state " that supervenes upon brain-lesions. 
Very often arising from such cause as acute myelitis, it is mistaken for a 
chronic inflammatory condition and denominated chronic myelitis or con- 
founded with ataxic paraplegia and even with locomotor ataxia. The 
descending degeneration in the pyramidal tracts is a consequence of any 
lesion which involves the upper motor neuron. When due to bi- 
lateral lesions above the cord it is best called a diplegia. Cross-lesions 
of the cervical cord are usually promptly fatal, so that the paraplegic 
state arising from indiscriminate lesions only reaches its later and 
characteristic development in cord lesions below that level. 

Etiology. — All the indiscriminate cord lesions, such as traumatism, 
hemorrhage, thrombotic softening, myelitis, tumors, and pressure from 
meningeal and spinal diseases and growths, give rise to a paraplegia 
which is more or less pronounced in proportion to the extent of the 
lesion. In addition, the so-called system lesions which are marked by 
sclerotic degeneration of the lateral tracts produce paraplegic conditions, 
but without distinct anesthesia. We find it also in Little's disease, 
ataxic paraplegia, family cerebellar ataxia, and amyotrophic lateral 
sclerosis. The only common fact is the degeneration of the motor tracts 
in the lateral columns. Diseases of the upper neuron arising from intra- 
cranial lesions have been considered in connection with diseases of the 
brain (Part III). 

Symptoms. — The symptoms of this secondary state vary greatly 
and are dependent upon the nature, extent, and activity of the initial 
lesion. In the system diseases the spastic paraplegia, as in Little's dis- 
ease, may be really a diplegia from embryonic defect, and congeni- 
tally present. In the family ataxias the defect is also teratological, 
but the symptomatic development is postnatal and usually insidious. 
Ataxic paraplegia and amyotrophic lateral sclerosis also develop very 
gradually and usually in adult life. They all in common possess defects 
of the pyramidal tracts marked by loss of muscular control and 
strength especially developed in the lower extremities, and by increased 
reflexes and spasticity. The special paraplegic features which they 
possess will be taken up in the description of the various system dis- 
eases. In this present connection the paraplegic state arising from 
indiscriminate lesions is principally in view. 

If the initial cord lesions be acute, as in traumatism, hemorrhage, and 
myelitis, the motor loss is promptly established and the muscles are 
flaccid and inert. The sphincters are usually relaxed. The reflexes 
represented in the diseased cord segments are abolished and those below 
the injured focus are diminished. If the cord is entirely severed, they 
are completely and permanently lost and rigidity does not ensue. When 
the cord is not entirely divided, at the end of a week in some cases, in 



374 



DISEASES OF THE CORD PROPER. 



others several weeks later, the increasing reflexes indicate degenerating 
lateral motor tracts and usher in the spastic features that are to 
permanently remain. 

When the inciting cause of the paraplegia is of gradual develop- 
ment, as in pressure conditions arising from Pott's disease and spinal 
neoplasms or new growths in the membranes or cord, the clinical pro- 
gram is very different. Root pains, girdling the trunk or streaking into 
the limbs, depending on the segment location of the lesion, are early 
symptoms and usually there is complaint of heaviness, weakness, and 
clumsiness in the legs. This increases either steadily or by stages, in 
the intervals of which some amelioration may occur, and eventually the 
hypersensitive girdle and subjacent anesthesia are more or less well de- 
veloped. Sphincteric loss is a late feature and is usually preceded by 
months of slighter degrees of incontinence. As the pressure increases, 
compression of the pyramidal tracts gradually develops ; they degener- 
ate and the reflex activity is correspondingly exalted. It is in these 
cases of slow cord compression that the spasticity, reflex automatism, 





Fig. 132.— Paraplegic gait. 



Figs. 133 and 134.— Station in spastic paraplegia due 
to syphilitic myelitis, showing rigidities, flexed knees, 
and adducted thighs. 



and muscular rigidity with resultant contractures reach their highest 
exemplification. 

AVhen the acute cases have improved enough to walk or the insidi- 
ous cases have attained a fair degree of development, the gait is highly 
characteristic. The patient's feet once planted seem glued to the floor, 
and the upper portion of the body is inclined forward in advancing. 
The pelvis is elevated on one side and that limb is then brought or 



INDISCRIMINATE CORD LESIONS. 



375 



dragged to a position under the center of gravity like a rigid pendulum 
(Fig. 132). It may even be aided by the hand. As it advances it is 
shaken by clonic movements, and when planted these may cause it to 
execute several dancing steps before it is securely placed, during 
which the heel is forcibly elevated and the patient may be bodily 
jostled up and down. The body is then again inclined forward over 
the supporting limb, and the opposite member is in turn carried a 
little in advance of its fellow. These short, jerky, halting, cloni- 
cally disturbed steps are frequently rendered more difficult by the over- 
action of the adductors of the thighs which displace the limbs inward, 
cause the knees to interfere with each other, and sometimes even induce 
a cross-legged gait. Progress, in spite of the disturbance of the gait, is 
usually made in a fairly straight line, unless some slight obstacle over 
which the patient is sure to stumble, or an unusual amount of clonus, 
cause him to swerve. In nearly every respect the gait is the opposite 
of the steppage of multiple neuritis. 

If walking is impossible, the attitude in standing may still indicate 




Fig. 135.— Paraplegia from spinal fracture. Attitude in bed. 

over trochanter. 



Thighs adducted and crossed. Bedsore 



the spastic state. The tendency to contracture usually draws the knees 
forcibly together and partially flexes the knee- and hip-joints (Figs. 133 
and 134). A sudden reflex contraction of the calf-muscles may cause 
the patient to rise on his toes or throw him to the ground. The knees 
often suddenly give way. 

When the patient is bedridden and the paraplegic state is developed 
to an extreme degree, the lower limbs may be rigidly extended on the 
pelvis and at all their joints. Adduction is strongly marked and may 
even cross the limbs. If one foot be lifted from the bed, the rigidity 
may serve to cause the other one to follow, as if the hip- and knee-joints 
were ankylosed. In other severe cases flexion predominates, and the 
lower extremities are rigidly folded upon themselves and upon the trunk, 
so that the heels are drawn up to the buttocks, the knees to the sternum. 

The reflexes are always exaggerated after the early flaccidity of 
acute cases has receded, and in the later stages become excessive to an 
incredible degree. The slightest tap on the patellar tendon forcibly 
throws out the leg, and the whole extremity may be seized with a clonic 
activity that provokes jerky, more or less rhythmical, movements which 
may also appear in the opposite limb, and finally end by a jack-knife 
contraction that violently flexes both extremities upon the trunk and at 
the knees. These reflex storms may even follow the slightest cutaneous 
impression, such as gently removing the bed-clothing, and are not infre- 



376 DISEASES OF THE CORD PROPER. 

quently the source of much pain and suffering. The vesical and rectal 
reflexes usually work automatically in protracted cases of paraplegia, 
and are only slightly under the patient's control, or entirely beyond it. 
Lesions in the lumbar cord may destroy them. When the upper dorsal 
or lower cervical cord is affected, priapism is frequently present, and 
cervical lesions cause dilatation of the pupils. 

All of these conditions vary from the slightest to the most extensive 
degree in different cases. Slow compression of the cord, as by tumor, 
gives the most highly colored picture, ataxic paraplegia perhaps the least. 

The amount and character of the sensory disturbance naturally de- 
pend on the extent of damage to the posterior half of the cord. 
Atrophy of muscles is in the same way dependent upon the destruction 
of the anterior gray and is related to the vertical extent of that destruc- 
tion. More or less general emaciation, due to inactivity and depressed 
systemic conditions, is commonly present. Contractures produce de- 
formities that still further cripple the patient. 

The prognosis naturally depends on the character of the cord 
lesion. The removal of pressure in Pott's disease and in spinal tumors by 
operation, frequently results satisfactorily and the cord functions return 
to a normal state. When the spasticity is the result of destructive le- 
sions of the cord, as in myelitis and traumatism, some disability is bound 
to persist. It may eventually be very slight or it may progressively 
increase. Every case must be individually considered. 

Treatment. — The treatment of the paraplegic state consists of: (1) 
Removing the cause if possible ; (2) preventing contracture distortions 
or correcting them by surgical means, such as tenotomies and orthope- 
dic apparatus ; (3) the use of electricity and massage to atrophied 
muscles j (4) general measures to build up the systemic condition ; (5) 
local applications over the spine to control any lingering inflamma- 
tory state or to hasten absorption of exudate, and (6) of the administra- 
tion of spinal sedatives to reduce the reflex excess. Local conditions, 
such as indolent ulcers, cystitis, and incontinence, furnish their own 
indications. It will often be found that massage and electricity pro- 
duce so much reflex stimulation that they must be discontinued. Hot 
baths often produce a grateful relaxation. Counterirritation to the spine 
and the resources of hydrotherapy sometimes are of great advantage. 
Following Foerster's T plan many cases have been treated with great 
benefit by the division of the posterior nerve-roots. 

LANDRY'S PARALYSIS (ACUTE ASCENDING PARALYSIS), 
The case observed by Landry, 2 reported in 1859, presented these 
striking peculiarities : An acute paralysis beginning in the legs, extending 
to the trunk and arms, soon involving the bulbar centers, and terminating 
fatally. The paralysis was not marked by loss of sensation ; the sphinc- 
ters were not involved. The muscles retained their faradic irritability, 
the mind was not disturbed, and the temperature was practically normal. 
No changes were found in the central nervous apparatus by microscopical 
examination, but the spleen was acutely enlarged. 

Since that time several hundred cases have been reported as instances 

1 "Zeitschr. f. Orthopsed. Chir.," 1903. 2 "Gazette Heb.," 1859. 



IXDISCRIMIXATE CORD LESIOXS. 377 

of Landry's paralysis, some of which correspond closely to, while others 
depart materially from the original outline. Of these latter we may 
say that most of them were cases of multiple neuritis, some were cases 
of poliomyelitis anterior, and others were cases of cross or disseminate 
myelitis with extension. With improved methods of investigation 
there has gradually accumulated a considerable number of cases which 
are clinically true to the prototype, but show organic disease in the 
spinal, bulbar, and even in the cerebral matter and in the nerve- 
roots and peripheral nerves. With the development of bacteriology 
we may now add typical cases in which infectious bacteria have 
been observed in the spinal cord or obtained by cultures from it. We 
are, therefore, justified in defining Landry's paralysis as an acute infec- 
tious ascending paralysis due to an infectious or toxic condition that may 
induce a myelitis largely confined to the anterior gray matter of the 
cord and which may, in addition, cause root involvement, peripheral 
neuritis, and changes in the medulla and cortex of a similar nature to 
those in the cord. It is not unlikely that the entire symptom-group of 
Landry may eventually be classed as acute poliomyelitis with ascending 
features. Such cases occur in every epidemic outbreak of that disease. 
Etiology. — This form of spinal palsy is about four times as fre- 
quent in adults as in children, according to the tabulation of selected 
cases by Bailey and Ewing, 1 and affects males nearly three times 
as often as females. It has followed close upon or occurred during 
attacks of numerous infectious diseases and conditions. Small-pox, 
tuberculosis, typhoid, pneumonia, diphtheria, syphilis, influenza, pelvic 
cellulitis, the puerperium and obscure febrile disturbances have seemed 
to play a part in its inception. Alcoholism 2 and exposure to cold are 
also rather frequently mentioned, but in numerous cases not the slightest 
cause has been detected and the patient apparently was in good health 
previous to the paralysis. The toxic features of many of the alleged 
causes jump with the clinical manifestations which are highly significant 
of an infectious state, and coincide with the few bacteriological findings 
that have been reported. The idea of a toxemia which has an elective 
action for the spinal gray producing first dynamic conditions, later fol- 
lowed by histological changes, best explains the various postmortem 
findings and the clinical manifestations of the disease. E. F. Buzzard 3 
isolated a micrococcus in pure culture from the blood of a case of 
Landry's paralysis and apparently the same organism was found in 
large numbers in the dura mater of the same patient. Subdural injec- 
tions of the cultivated coccus produced rapidly spreading paralysis in 
a rabbit and the organism was again obtained from the blood and dura. 
The changes in the nervous system of the patient and rabbit were of 
the kind produced by toxins and in neither could the microbe be dem- 
onstrated in the nervous structures or even in the pia arachnoid. That 
the infection or toxin reaches the cord through the blood is abundantly 
shown by the perivascular changes, and the frequent limitations of the 
myelitic invasion to the territory irrigated by the anterior median arte- 
ries and the vessels reaching the anterior horns along the motor roots. 

1 "N. Y. Med. Jour.," July, 1896. 

2 Krewer, "Zeitschr. f. klin. Med.," Bd. xxxii. 3 "Brain," Spring, 1903. 



378 DISEASES OF THE CORD PROPER. 

Morbid Anatomy. — In the older reports, as in the first instance, 
no morbid changes were detected anywhere in the nervous system. As 
methods improved and data multiplied, reports of myelitic softening, 
especially in the gray matter, but also implicating the neighboring white 
fibers of the dorsal and cervical cord, degeneration in root-fibers and peri- 
pheral nerves, and, finally, changes in the medulla, cerebrum, and cere- 
bellum were made. A majority of cases, whether showing cord changes or 
not, presented an acutely enlarged and softened spleen and often engorged 
lymphatic glands. Of late no case that has been systematically and com- 
petently examined has given negative findings. The cellular structures 
of the anterior gray or the cylinder processes arising in the motor cornual 
cells are found disturbed. Eisenlohr, Ross, Hoffman, Immerman, Cursch- 
mann, Ketli, Hlava, Marinesco, Bailey and Ewing all found such 
changes varying from fragmentation of the cylinder process or slight 
swelling of the cell bodies and chromophilic changes of the cell proto- 
plasm to well-defined poliomyelitis and diffuse cellular infiltration 
throughout the spinal gray. Frequently the blood-vessels show a peri- 
vascular small-cell infiltration and the motor cells present marked de- 
generative changeSo In cases of sufficient intensity and duration the 
peripheral nerves are degenerated and muscular degeneration and even 
atrophy are added. The cranial nerve nuclei and the cellular and vas- 
cular elements of the cerebral and cerebellar cortex were similarly 
affected in Ewing* s case. 1 

Bacteriological examinations have sometimes been made with nega- 
tive results and suitable stains have often failed to show bacteria in the 
cord sections. Remlinger 2 met with this experience even when cultures 
from the cord readily developed streptococcus pyogenes and streptococci 
were also found in the lymph-spaces of the gray matter of certain other 
portions of the cord. Eisenlohr found the staphylococcus pyogenes 
aureus in all cultures and staphylococcus aureus in cultures from the 
spleen. Centanni found a rounded bacillus in the peripheral nerves. 
Giuzetti found chromogenic bacilli in cord cultures. Marinesco found 
cocci in the ganglion-cells. Roger and Josne 3 have demonstrated the 
pneumococcus. Thoinot and Masseline have produced spinal paralysis 
in rabbits by the intravenous injection of staphylococcus pyogenes aureus 
and of bacillus coli. With the newer methods and findings in poliomye- 
litis to guide, it is probable that the identity of Landry's paralysis with 
the infantile variety will be proved in many cases. 

Symptoms. — Acute ascending paralysis may develop during an 
attack of some infectious disease or may follow it. In several epi- 
demics of poliomyelitis such cases have been encountered. Fre- 
quently, however, it comes on without malaise, fever, or premonitory 
symptoms, usually without tingling, numbness, or other sensory disturb- 
ance. A feeling of weakness begins in the feet and legs, and slowly creeps 
upward, becoming more and more pronounced in the lower levels as the 
disease mounts. It may affect one leg first or most. At the end of 
two or three days or a week the lower extremities are completely para- 
lyzed and the weakness has involved the trunk and upper limbs. The 

1 Loc. cit. 2 " Comptes Rendus de la Soc. de Biol.," April, 1896. 

3 "Presse Med.," July 27, 1898. 



INDISCRIMINATE CORD LESIONS, 379 

breathing becomes superficial from involvement of the thorax, and 
difficulty in swallowing soon appears. In severe cases every voluntary 
muscle below the face is completely paralyzed and relaxed, and even 
the cranial nerves may be involved, especially the oculomotor, facial, 
and hypoglossal. Cerebral and mental symptoms are absent until the 
dyspnea or cardiac failure is pronounced and induces them. The 
sphincters are not, as a rule, relaxed ; there is no tendency to bedsores 
or dystrophy ; the tendon and superficial reflexes are usually present ; the 
electrical responses are normal ; and sensation, together with the special 
senses, is not perverted. If a fatal issue do not occur, the symptoms 
of paralysis slowly recede in the reverse order of their appearance, and 
when they have distinctly subsided from the upper levels recovery may 
be anticipated. 

In some cases the onset is reversed, the upper extremities first 
showing weakness ; and, indeed, the ordinary type may be greatly 
modified, as can be readily understood from the varying anatomical 
distribution of the organic lesions in well-authenticated observations. 
In two cases falling under the writer's attention, the clinical his- 
tory was typical, complete Wasting of isolated muscle-groups in all 
four extremities occurred, and persisted for years, without any ap- 
pearance of ultimate improvement. Paresthesia and dysesthesia are 
not rare, and anesthesia may gradually follow the paralytic invasion, 
advancing in a similar manner. The reflexes may also subside and dis- 
appear in an ascending progression. Even electrical modifications and 
the reaction of degeneration are encountered. The progress of the 
paralysis may stop at any point, and then recede. A temperature of 
101° to 103° F. has been observed, but, as a rule, it does not rise 
above the normal. Profuse perspiration sometimes and splenic enlarge- 
ment frequently are encountered and bespeak the toxic state. 

Course. — The course from inception to fatal termination may be 
very brief, — less than two days, — and fatal cases usually end within ten 
days. Prolonged cases may only reach their acme in a month. After 
a stationary period of varying length in the hopeful cases, improvement 
takes place usually in a retreating order, but convalescence is slow and 
may require months. On the other hand, it may be rapid, or, as in the 
cases previously mentioned, permanent injury may result. 

Diagnosis. — The diagnosis in some cases must necessarily be 
extremely difficult, but in the typical form is readily made, providing 
the existence of this rare disease is kept in mind. It rests upon the 
method of invasion, the pure motor paralysis, the comparatively negative 
conditions as to reflexes, sensation, and electrical reactions, and the his- 
tory of some possible toxemic state. Somes cases are complicated by 
hysteria, which is capable of greatly obscuring the diagnosis. When 
slight electrical changes and paresthesia? are present, it is impossible to 
exclude neuritis, and the occurrence of peripheral nerve-lesions in some 
instances has already been pointed out. In meningitis the pain and 
rigidity are distinctive. In cross-myelitis we have all spinal cord func- 
tions involved below a definite level and lack the ascending features. 

Prognosis is always grave, since even in the irregular and prolonged 
cases one can not foretell at what moment bulbar symptoms may appear, 



380 DISEASES OF THE COED PROPER. 

and the main danger to life depends on their presence. Rapidly 
ascending symptoms imply a speedy termination, but there is no 
invariable rule. Only when the tide has turned and symptoms are 
receding can one entertain a reasonably hopeful prognosis. The pres- 
ence of neuritic conditions or of electrical changes implies a prolonged 
convalescence and doubt as to ultimate complete recovery. Where 
cerebral symptoms appear they are of bad import, signifying either 
profound toxic conditions or the near approach of death from cardiac 
or respiratory failure. 

Treatment will be directed against any general toxic condition pres- 
ent or reasonably suspected. The salicylates, tincture of the chlorid of 
iron in full doses, bichlorid of mercury to the point of toleration, thor- 
ough cleansing and disinfection of the alimentary tract, supportive diet, 
conservation of nervous energy and strength, are valuable. Uro tropin 
in 10-grain doses every six hours may be expected to have a beneficial 
influence upon the cord infection. To the spine a narrow sinapism the 
whole length of the back, frequently repeated, is of service; even the 
thermocautery is advised by some. The paralyzed limbs should be 
gently massaged to improve circulation and give comfort. When 
swallowing becomes difficult or impossible, feeding by the stomach, 
nasal, or rectal tube must be adopted, and the preference is for the nasal 
tube, providing care be exercised to avoid passing it into the larynx. 
During convalescence, massage, electricity, local douches, tonics, gener- 
ous diet, and general measures are the main reliance. 

CAISSON DISEASE, OR DIVERS' PALSY* 
Workmen and others subjected to high atmospheric pressure, as in de- 
scending to great depths in diving apparatus, or in making certain exca- 
vations by caisson construction, are frequently affected with cerebral 
symptoms and paralytic conditions of mainly a paraplegic character. 
The disturbance varies in intensity from slight giddiness and neuralgic 
pains to paraplegia. Even sudden death may occur. The symptoms 
appear while the air-pressure is being reduced, or within the following 
half-hour. In a minor degree, high altitudes, as in mountain climbing 
and ballooning, furnish analogous conditions and symptoms. 

Etiology. — The cause of divers' palsy is not so much the increased 
atmospheric pressure, as its sudden reduction. A number of predispos- 
ing causes have also been fairly determined. Advanced age, alcoholism, 
heart and kidney disease, obesity, hunger, and any condition of physical 
depression furnish a liability to its onset. On the other hand, those 
who have for months been gradually subjected to increasing air-pressure 
acquire in some degree an immunity by habituation. The length of ex- 
posure and the amount of pressure are followed by proportionate effects, 
but symptoms rarely result unless the pressure reach two atmospheres — 
thirty pounds. 

The mechanism producing the palsy or the slighter symptoms is fur- 
nished by the vascular apparatus. Various theories have been advanced 
to explain the results. One supposed that during the time of increased 
air-pressure the superficial and peripheral parts of the body are exsan- 
guinated and the central organs actively congested to a similar degree. 



INDISCRIMINATE CORD LESIONS. 381 

and this congestion reached such a point that the capillary field became 
paretic from distention, and could not promptly deliver itself of its super- 
abundant blood when pressure was removed from the periphery. A 
passive congestion then was supposed to ensue, with a stagnant blood- 
current. The lower cord is placed at an especial disadvantage through 
its arterial arrangement, which mechanically conduces to maintain the 
vascular stagnation. Serous effusion into the cord and meninges thus 
followed, or the effusion might be hemorrhagic. 1 This idea of increased 
arterial tension may be entirely discarded, as careful tonometric exam- 
inations before, during, and after working in compressed air clearly 
disprove it. 2 

A more important feature is the condition of the intravascular gases. 
The oxygen, nitrogen, and carbon dioxid of the blood, compressed under 
the high pressure, are liberated by restored low pressure, and, expanding, 
fill the vessels with gaseous bubbles, producing something like an air 
embolism. The gases also escape into the tissues. Catsaras, of Athens, 
has seen gas bubbles in the vessels and even in the cord parenchyma 
of dogs subjected to high air-pressures, and gas has been seen in the 
tissues and vessels in some human autopsies after death from this cause. 
M. A. Starr, in his book on Nervous Diseases, photographically illus- 
trates this condition in both the brain and spinal cord. If vascular 
accidents do not follow, the circulation is gradually equalized, the gas 
is absorbed or removed by respiration, and symptoms subside. P. Bert, 
Hoche, 3 Snell, 4 and Bassoe 5 have practically proved the gas theory. 
Edemata, effusions, and hemorrhages naturally produce more or less 
lasting symptoms in the brain, and especially in the cord. 

Morbid Anatomy. — In the few autopsies on record, which have 
all been made some days or weeks after the onset of the attack, the 
cord has always been found abnormally congested. Small hemorrhages 
have been seen and diffuse myelitis with degenerative tracts have been 
noted. In some cases there has been an edematous condition of the 
membranes and cord. Hemorrhages into parenchymatous organs and 
mucous surfaces have also been observed. The secondary myelitis is 
most pronounced in the dorsal half of the lumbar cord and the anterior 
horns are practically unaffected. In other words, that portion of the 
cord which has the best vascular supply, and where stasis and edema 
would first subside, ordinarily escape injury. The painful manifesta- 
tions of the attack are perhaps explained by the location of the vascular 
disturbance in the sensory portion of the cord. 

Symptoms arise as the air-pressure is being reduced, or shortly 
thereafter, and may appear while the men are in the locks or chambers 
that are placed between the various pressures or after the patient has 
gone some distance in the open air. At first the cerebral features pre- 
dominate; headache, giddiness, faintness, nausea, vomiting, delirium, 
double vision", and even coma may precede or accompany the spinal 

1 Hirt, " Handbuch der spec. Pathologie und Therapie," vol. i. 

2 H. Brooks, "Med. Rec," May 25, 1907. 

3 Berlin, klin. Wochens.," May 31, 1897. 

4 " Compressed-air Illness," London, 1896. 

5 " Compressed-air Disease," Report of Commission on Occupational Diseases, Chicago, 
1911. 



382 DISEASES OF THE CORD PROPER. 

symptoms. These consist of paroxysmal pains, frequently of great in- 
tensity. They usually are felt in the legs, but may affect the trunk or 
upper limbs. Their relation to the posterior portion of the cord has 
already been mentioned. Soon the patient feels numbness and weak- 
ness in his legs, which may increase rapidly to complete paraplegia, 
usually confined to the lower extremities, but it may extend downward 
from any spinal level. It involves motion, sensation, and the sphinc- 
ters, and presents clinically the features of a cross-lesion of the cord of 
rapid onset. In extreme cases the patient falls dead, or, after stagger^ 
ing a little, falls and expires with or without delirium and convulsions. 
Symptoms may be most variously combined and show any grade of inten- 
sity. The majority recover promptly. Of those coming under treat- 
ment about one-half recover, about half have lasting paralysis, and 
about three per cent. die. Those who do not recover within the first 
three or four days present the symptoms and run the course of a lumbar 
or dorsal myelitis of varying extent and severity. In a study of 310 
cases occurring during a period of several years in New York Starr x 
lists the frequency of symptoms as follows : Bends or myalgias, 105 ; 
aural symptoms, often with vertigo and rupture of drum-heads, 68 ; 
pain in the joints, often with swelling, but no inflammation, 60 ; acute 
paraplegia, 26; monoplegia, 17; cerebellar symptoms, 14; asphyxias 
or syncopes, 13 ; aphasia, a few. 

Treatment. — Prophylaxis. — Persons who are to be subjected to 
increased air-pressure should be rigidly examined. Those presenting 
the predisposing conditions mentioned should be excluded. Only hardy 
young men with sound hearts and regular habits should be accepted for 
this work, and spare individuals are preferable. In case of an extensive 
undertaking the same men should be employed throughout the task, that 
they may be habituated to the increasing pressure as the work progresses, 
thereby gaining immunity. In a pressure of over thirty pounds they 
should w r ork short shifts of two hours or less, and plenty of time should 
be taken in passing the locks. Smith 2 says five minutes for each fifteen 
pounds of extra pressure. Inexperienced persons should take much 
more. It is well not to enter the pressure fasting. Snell lays stress 
on ventilating the works to reduce the amount of gases in the circula- 
tion as well as on general principles. 

Treatment of the Attack. — If symptoms arise, the patient should be 
hurried back into the caisson, and if the symptoms subside, as they 
often do, very slowly returned to the outer air. Morphin is often 
required for the intense pain. Ergot in dram doses of the fluid 
extract every hour will sometimes relieve the pain and apparently 
check the disease. It has been suggested to bandage the limbs, and 
even the trunk, thereby restoring something of the surface pressure 
and maintaining the spinal circulation. When paralytic features have 
developed, the treatment is that of myelitis. 

TUMORS OF THE SPINAL CORD AND ITS VARIOUS ENVELOPES, 
New growths arising in the spinal meninges or on the inner surface of 
the bony canal or in + he cord itself produce definite symptoms only as the 

1 "Med. Rec," June 19, 1909. 2 Pepper's "System of Medicine," vol. iii. 



IND1 SCRIM IN ATE CORD LESIONS. 



383 



cord or the nerve-roots are disturbed. They may be properly grouped 
together because of their common symptomatology, which renders a 
positive clinical diagnosis as to their original sites impossible, and makes 
every operation for their removal in a limited sense an exploratory one. 
The importance of an early diagnosis of these tumors is emphasized by 
the fact that most of them can be successfully removed if taken in time, 
and the fatality, which otherwise attends them, averted. The paraplegia 
to which they give rise may in the same way be prevented, and in some 
instances caused to recede when not too far advanced. 

Tumors arising from the meninges aud extradural structures are 
about six times as numerous as those primarily cordal. Sarcoma and 
its varieties furnish more than one-third of the 
tumors, tubercle and echinococcus each about a 
tenth, and carcinoma and all varieties of benign 
growths, including gumma, the balance. Glioma, 
which is so common in the brain, also appears in 
the cord. It is usually, however, distributed 
closely about the central canal or in longitudinal 
bands in the substance of the cord, where, under- 
going degeneration, it produces channels or false 
canals. These give rise to definite symptoms and 
a clinical type, which is called syringomyelia. It 
is described in a later chapter. 

Tumors affecting the spinal cord are usually 
of small dimensions, owing to the rapidity with 
which they destroy the cord and lead to a fatal 
issue. They are commonly single, but several 
tubercular growths and multiple sarcomata and 
neuromata have been reported. The favorite 
location of spinal growths is in the dorsal and 
lower cervical regions. Regarding the causation 
of spinal tumors, the same ideas exist as pertain 
to the development of tumors elsewhere. Trau- 
matism is often alleged and may undoubtedly 
serve to locate a syphilitic process and perhaps to 
favor the invasion of tubercle and angiomatous 
growths. Its relation to malignant neoplasms is 
largely supposititious. 

Morbid Anatomy. — The post-mortem ex- 
amination reveals the new growths arising from 
the extradural tissues, the membranes, or the 
cord, in the substance of which it may rarely be 
embedded. 

It frequently is traversed by several nerve- 
roots, or these may be destroyed. It may have a vertical extent of 
several inches. From pressure upon the cord there is a zone of softened 
cord-substance which frequently shows an inflammatory condition. The 
cord may be much indented by the growth, or compressed almost to 
complete division. Changes in the cord substance due to pressure- 
atrophy, softening, and myelitis are present, with resulting secondary 



v' w'i 



136. — Tumor of the cord 
(Leyden). 



384 DISEASES OF THE CORD PROPER. 

degenerations related to the portion of the cord that is affected. The 
consequences of myelic softening and myelitis are found in the mus- 
cles, bladder, kidneys, etc., depending in distribution upon the anatom- 
ical and clinical features of the given case. The various growths are 
marked by their ordinary individual characteristics and histological 
peculiarities. Subdural cysts containing clear fluid are sometimes en- 
countered either alone or in association with tumor formations. When 
existing alone, Oppenheim denominates the condition meningitis serosa 
spinalis circumscripta, and several such cysts may be found in a 
given case, in some instances blocking the flow of spinal fluid, especially 
downward, and even causing pressure changes in the cord. Tumors 
and cysts, especially when located in the cervical region, may be attended 
by more or less hydrocephalus, with its complicating symptoms. 

Symptoms. — The initial and most common symptom of spinal 
tumor is usually pain. This is of two varieties : first, that referable to 
irritation of the posterior roots, and, second, that due to disturbance of 
the sensory tracts in the cord. The first gives rise to girdling sensa- 
tions and partially follows in distribution the fields of the peripheral 
nerves. The second follows the segmental outlines and may also give 
rise to pains referred to parts below the lesion whose sensory pathways in 
the cord are irritated. If these pathways are broken, the pain may be 
referred to an area actually anesthetic. The root pains and the segmental 
or cord pains are frequently combined. Ordinarily the pain is bilateral. 
It may occur first on one side, but, arising as it usually does from pres- 
sure upon the cord, it is evident from the anatomical situation that pres- 
sure and counterpressure must be equal and the whole diameter of the 
cord soon affected. When the tumor is within the cord and laterally 
situated, a partial Brown-Sequard palsy may develop at first, but ordi- 
narily soon yields to the cross variety and the paraplegic syndrome. 
The pains are of all degrees of severity, but frequently atrocious in 
their intensity, of a lightning, darting, ripping character, with parox- 
ysms and remissions. Exceptional cases run an entirely painless course. 

The nerve-trunks are so rarely sensitive that Starr, 1 in a masterly 
resume of the subject, states that he never noted it in his own experience 
or in the literature. Pain over the seat of the tumor is also rare, and, 
when present, following the usual rule, is felt one or two inches below 
the level of the lesion. 

The reflexes comport themselves as in the paraplegic state gener- 
ally (see p. 373). Those which find their nuclear representation in 
the diseased segments are lost early. Those below the lesion are exag- 
gerated as the compression is brought to bear, and, in extreme cases 
reach the highest degree of intensification. Should the cross-lesion of 
the cord become absolute, constituting a cord-division, all reflexes are 
lost below the affected level. The rectal and vesical reflexes are sub- 
ject to the ordinary rules of the paraplegic state. Motor disturbances of 
a paraplegic sort rarely precede the sensory disturbance, but usually 
follow it pari passu with the reflex manifestations. The feet and legs 
feel heavy, clumsy, and weak. This paresis becomes more and more 
pronounced as the pressure increases; the spastic gait is developed, and 
1 "Am. Jour. Med. Sciences," June, 1895. 



INDISCRIMINATE CORD LESIONS. 385 

finally the patient becomes bedridden. Absolute motor loss is the great 
exception and depends, like complete reflex obliteration below the lesion, 
upon division of the cord. 

With the motor loss, again, there is usually blunting of cutaneous 
sensation, and finally complete anesthesia, of paraplegic distribution, 
surmounted by the hypersensitive band. Tumors in the cervical region 
may occasion cerebral symptoms : headache, choked disk, vomiting, and 
the hydrocephalic syndrome. 

To again follow Starr, the order in which these symptoms arise is 
commonly : (1) Peculiar pains of limited distribution ; (2) increase of 
reflexes below the lesion ; (3) paraplegia ; (4) loss of sensibility, and (5) 
loss of all subjacent reflexes. Bedsores and dystrophic joint-disturbance 
occur late in tumor, or may appear earlier upon the addition of an acute 
myelitis. Collins * names the clinical order of symptoms as follows : 
Sensory, motor, visceral, trophic, and topical ; the topical consisting in 
tetaniform rigidities caused by pressure over the spine in the region of 
the tumor and in rare cases deformity of the spinal column. 

Xonne 2 calls particular attention to a yellow color of the spinal 
fluid found in several cases of spinal cord tumor and to an increase of 
albumin in the fluid. Raven 3 has tabulated 47 cases in which increased 
albumin was noted without any cytological increase. He attributes 
the yellow color to blood-pigment. The nature and location of the 
tumor has no relation to the changes of the spinal fluid. Occasionally 
tumor cells have also been found. 4 

Course and Prognosis. — The course of the disease is usually slow 
from the insidious onset to the fatal termination by exhaustion due to 
pain, or the consequences of myelitis, cystitis, pyelonephritis, bedsore, 
and septicemia. The rapidity of the disease depends upon the char- 
acter of the growth, but tubercle is frequently of unexpected activity 
and may induce a complete paraplegia within a few weeks. In rare 
instances years have been consumed in the development of the tumor. 
The natural tendency is to paraplegia and death. The location of the 
tumor in the cervical or lumbar enlargement hastens the course of events. 

The prognosis in tumor involving the cord, excepting gumma, is uni- 
formly bad, and practically fatal without operation. 

Diagnosis. — The diagnosis of cord-tumor depends mainly upon the 
insidious onset and the order of development of symptoms. The slow 
compression of the cord gradually induces the paraplegic state with 
intense spasticity, but is preceded by the localized, persistent, and uni- 
form root or segment pains. A cross-myelitis is ordinarily of sudden 
onset and not especially painful unless the meninges are affected. In 
that event the pain is diffuse and intense over the spine. Bedsores and 
trophic disturbance are early features of myelitis, late ones of tumor. 
The presence or history of new growths elsewhere aids the diagnosis, 
and the location in the dorsal cord is of some significance. In Potfs 
disease we soon have rigidity of the back, pain upon rotation or percus- 
sion or jars of the spine, and later vertebral thickenings and defor- 

1 "N. Y. Med. Rec," Dec. 6, 1902. 

2 "Deutsch. Zeitschr. f. Xervenheilk.," Bd. 38, 1910. 

3 Ibid., Bd. 44, 1912. 4 Mohr, Ibid., p. 418. 

25 



386 DISEASES OF THE CORD PROPER. 

mities. The nerves are sensitive and the pain accurately follows the 
nerve-trunks as a rule. 

The location of the tumor is deciphered by reference to the general 
rules of cord-localization, especial importance attaching to the position 
of the early pains and the upper levels of dysesthesia. As already indi- 
cated, it is usually impossible to clinically determine whether a growth 
is vertebral, meningeal, or cordal, and operations are, therefore, to this 
extent exploratory. A Brown-Sequard paralysis, followed by a para- 
plegia, or analgesia preceding anesthesia, or limited early muscular 
atrophy, may indicate that the growth is probably within the cord. 

Speculation as to the nature of the growth is based on those general 
features which are common to growths in all localities. The presence 
of malignant growths elsewhere points to a secondary neoplasm of the 
same order. Tuberculosis and syphilis have their own indications. It 
may also be borne in mind that sarcoma is the most common form 
of tumor in this location. 

Treatment. — With the exception of gummata, which are to a con- 
siderable degree amenable to antisyphilitic treatment, the only course 
that promises relief is surgical operation. It is evident that tumor with- 
in the cord-substance can not be removed without great and permanent 
damage to the cord. It is also evident that if the compression from 
without has caused local cord-disintegration, an operation can at best 
only check the harm at that particular stage. Malignant neoplasms 
are very likely to recur, and are frequently secondary to large growths 
elsewhere that have already jeopardized life. Tubercle is also often 
secondary to a process that may leave little hope of prolonged existence. 
The fact, however, remains that without removal the cord-tumor itself 
will induce a fatality, preceded usually by the most intense suffering and 
the most abject helplessness. Even when an operation can do nothing 
but relieve the pains due to the local irritation, it may be favorably con- 
sidered. 

On the other hand, about seventy per cent, of recorded cases were 
operable, and out of thirty-three operated cases, tabulated by Putnam 
and Warren, 1 over one-half resulted successfully. Similar figures are 
given by Starr and also by Bruns. 2 Stursberg, 3 in a more recent and 
larger tabulation of reported cases, shows 32.2 per cent, of cures. Early 
diagnosis and prompt operation will materially improve the average. 

SPINA BIFIDA. 
Spina bifida is an embryological defect due to the failure of the neural 
canal to completely close in the posterior median line. As a result, the 
bony arches of the vertebra? are defective. This may be indicated by a de- 
pression, spina bifida occulta, or by a tumor made up of the contents of the 
spinal canal variously arranged. Its usual location is in the lumbosacral 
region, as the neural canal closes from above downward and is last com- 
pleted at the caudal extremity. When present, it serves to fix the lower end 
of the cord to the corresponding vertebrae, and the normal recession of the 
conus medullaris to the level of the second lumbar vertebra is prevented. 

1 "Am. Jour. Med. Sciences," Oct., 1899. 



'Die Geschwiilste des N erven-Systems." 



3 "Centralbl f. Grenzgebiete der Med. u. Chir.," 1908. 



INDISCRIMINATE CORD LESIONS. 387 

The simplest variety is the rare meningocele, which is usually covered 
by skin and consists of a pediculate or pedunculate sac of spinal mem- 
branes continuous with the arachnoid spaces. Neither the cord nor the 
nerves enter it, and deformities of the cord or disabilities in the legs and 
sphincters are absent. 

The ordinary tumor in spina bifida is the meningomyelocele, made up 
of both the cord and the meninges and usually attended by deformities 
and paralysis in the legs and sphincters. The cord ordinarily is 
flattened out in the posterior surface of the tumor, which is more or 
less translucent, devoid of true skin, and only covered by a layer of 
epithelium. From this posterior situation the flattened and deformed 
cord-substance gives off the nerve-roots, which run forward through the 
sac into the intervertebral foramina. In the most prominent part of the 
tumor corresponding to the cutaneous defect and the location of the 
broadly spread cord-substance there is often a pit or umbilical depression. 

In rare and more pronounced deformities the central canal of the cord 
dilates with the tumor formation, hydromyelocele, and lines its cavity, 
with which it is coextensive. The nerve-roots now lie in the sac-walls. 
Again, in myelocele a flattened mass — not a sac — of neural tissue lies in 
the vertebral hiatus, containing a small opening leading into the cerebro- 
spinal canal. Through this, cerebrospinal fluid constantly oozes. Both 
of these forms are rare, always attended by defects in the lower extrem- 
ities, and the latter, myelocele, is promptly fatal in a few days. 

Etiology. — The causation of this defect in the embryo, which 
dates back to the earliest days of impregnation, like similar terato- 
logical defects, is obscure. It has been attributed to injury. In a 
number of instances it has appeared in several children in the same 
family, and even in succeeding generations, showing hereditary trans- 
mission. Other children in the same family may present harelip or 
club-foot. It is more common in females than in males, in a ratio of 
about eight to seven. 

Symptoms. — Spina bifida is usually discovered at birth, but may 
exist unnoticed as a slight depression, often covered by hair for months 
or even up to adolescence, when the tumor may appear. At first usually 
small in size, it may rapidly increase. When the cord is involved in 
the sac, there is usually associated club-foot or undeveloped legs or 
sphincteric incontinence. The tumor is in the middle line and presents 
varying appearances due to its makeup. The opening in the vertebral 
arches can usually be detected by touch, but the contents of the tense, 
fluctuating, and slightly compressible sac are rarely palpable. Under 
excitement and in the erect position the sac increases in tension and size. 
Pressure upon it is likely to produce uneasiness, stupor, coma, and con- 
vulsions. The fluid contents correspond to and are identical with cere- 
brospinal fluid. 

The diagnosis is usually very easy, but it is more difficult to decide 
upon the exact nature of the tumor's makeup. The presence of defor- 
mities or paralysis in the limbs or of sphincteric incapacity and umbili- 
cation would indicate that the tumor was not a simple meningocele, but 
that the cord was involved in the sac-wall. An oozing aperture and a 
nevus-like mass of pinkish tissue would suggest myelocele. 



388 DISEASES OF THE CORD PROPER. 

Prognosis. — Only in the slighter forms of spina bifida is the progno- 
sis favorable. A pedunculated meningocele or mere depression is not 
incompatible with full vitality and perfect cord-functions. In the 
severer varieties, if the child lives, it will probably bear club-foot or 
other deformity and defect. The great majority of cases die during the 
first three months, cases of myelocele during the first three days. Rare 
cases have reached adult age and beyond. 

Treatment is purely surgical. In meningocele a fair prospect is 
offered to extirpation of the sac. In the other and more common varie- 
ties, to extirpate the sac or to obliterate it by injections is to destroy a 
portion of the cord-substance. In this condition the sac must be pre- 
served, and various osteoplastic operations have been suggested looking 
to the formation of a bony neural canal covered by cutaneous flaps. 
The deformities in the lower extremities and the paraplegic condition, 
of course, would not be benefited thereby. 



CHAPTER III. 

LESIONS PRINCIPALLY CONFINED TO THE GRAY 
MATTER OF THE CORD, AND DISEASES REFERABLE 
TO DISORDER OF THE SPINAL GRAY. 

In this chapter a number of diseases are brought together that have 
in common symptoms dependent upon disorder of the lower motor 
neuron. In some, anatomical changes are clearly defined ; in others 
there is reasonable presumption that eventually changes will be detected. 
The whole question of progressive muscular atrophy is in a transitional 
state, with a decided tendency to bring the various forms into close 
relationship. 

ACUTE ANTERIOR POLIOMYELITIS. 

Poliomyelitis anterior acuta, acute spinal paralysis, acute atrophic 
paralysis, spinal paralysis of children, essential paralysis of children, 
polioencephalomyelitis, Heine-Medins disease, and epidemic paralysis 
are the principal of the numerous names applied to an acute infective 
disease having a special selective action for the nervous system. It 
is marked by febrile and infectious symptoms, is of rapid onset and 
development, and promptly induces widespread muscular paralysis, 
a portion of which commonly remains permanently, and is then attended 
by local atrophy. It is often epidemic. 

Etiology. — The great majority of cases occur before the tenth year, 
and fully three-fifths under four years of age, with especial frequency in 
the latter half of the first year. During the first six months it is extremely 
rare or else passes undetected to a fatal end. It has been freely attrib- 
uted to dentition, to cold, and to traumatism, especially in the form of 
falls, but it is doubtful whether any of these alleged causes are of direct 
importance. In many instances it occurs in the course of or during 
the convalescence from infectious fevers, especially the exanthemata. 
Its infectious nature is further indicated by the abrupt onset, the usual 



LESIOXS AXD DISEASES OF SPIXAL GRAY. 389 

febrile movement, the gastric disturbance, the occasional occurrence of 
convulsions, and, most of all, by epidemic and endemic outbreaks. Such 
have been recorded by Colmer, 1 Cordier, 2 Medin, 3 Leegard, 4 Oxholm, 
Nonne, Calverly, 5 Altman, 6 Harbitz, 7 and the extensive epidemics in Xew 
York City in 1907, Melbourne in 1908, St. Paul, Minn., in 1909, by 
various reporters. August, September, and October are the months 
of maximum epidemic prevalence in the northern hemisphere, the cor- 
responding months below the equator, but sporadic cases may occur 
at any time, and frost does not immediately put an end to epidemics. 
Landsteiner and Popper 8 were the first to cause the disease in monkeys by 
the intra-abdominal injection of a bacterium-free emulsion of the spinal 
cord of a lad who died from the disease. Similar experiments were 
made by Flexner, Strauss, and Huntoon, and inoculation of monkeys 
remains the only positive means of verifying and testing the infection. 
It does not matter how or where the virus is introduced into the circu- 
lation, but it is proved that the nasal mucous membrane furnishes a 
ready entrance and is probably the usual avenue of both infection and 
of elimination. Moreover, infection carriers are common among those 
brought into contact with the disease, as was shown by Petterson, who 
recovered the virus from the nasal and bowel washings of such persons. 
The early age incidence and the general adult immunity to the disease 
lead to the inference that such immunity must be the result of previous 
unrecognized infection. It is well known that many cases of poliomye- 
litis do not cause paralysis. 9 Flexner has practically proved that one 
attack produces permanent immunity. This rule may have exceptions. 
I have seen a case presenting one attack at the age of seven and a second 
at thirty-two. According to Flexner, 10 to whom most that is known of 
the infection is due, the virus can be regularly detected, both in man 
and monkey, in the nasal mucous membrane, brain, spinal cord, and the 
mesenteric lymph-nodes, but not in other bodily organs or structures 
or the blood. The virus thriving best in brain and cord structures and 
membranes eventually brings about anatomical changes in the nervous 
system with resultant paralysis. The period of incubation in monkeys 
may be two or three days or four or five weeks, apparently depending 
upon the amount and quality of the virus and the degree of bodily 
resistance. From the nasal mucous membrane, where the virus thrives, 
part of it is swallowed, leading to the mesenteric gland infections and 
contamination of the gastro-intestinal cavity and contents. 

Aside from human carriers, it has been proved by Howard and Clark 
that bedbugs may so act, and Rosenau has shown that flies may trans- 
port the infection to monkeys either by contaminating their food or 
possibly by biting. All biting insects are under suspicion. 

1 "Am. Jour. Med. Sciences," 1843. 2 "Lvon Medicale," 1888. 

3 "Hygiene," 1890. 4 "Neurolog. Centralblatt," 1890. 

5 "N. Y. Med. Record," 1894. « "Australian Med. Gaz.," 1897. 

7 "Jour. A. M. A.," Oct. 26, 1907. 

8 "Zeitschr. fur. Immunitatsf. u. exp. Therap.," 1909, ii, 377. 

9 Frost, Bulletin No. 90, U. S. A. Public Health Service. 

10 "Jour. Amer. Med. Assoc. " Oct. 12. 1912. 



390 



DISEASES OF THE CORD PROPER 



The virus is extremely minute, readily passing through the pores 
of the finest porcelain filters. In many ways it resembles the virus of 
rabies. Flexner and Lewis and Levaditi have produced an opalescence 
in bouillon cultures, in which Levaditi detected extremely minute bodies 
of oval shape. Romer and Joseph, by means of the ultramicroscope, 
found similar bodies in the Berkefeld filtrate. Flexner and Noguchi 1 
have, however, discovered an extremely small globoid organism that 
will pass through a Berkefeld filter, propagates in ascitic fluid under 
anaerobic conditions, and produces poliomyelitis in monkeys, from 
which it can be recovered. It is also found by a special technic in 
the tissues of human cases and the experimental monkey cases. 2 It has 
been found in the blood by Amoss. 

In some of these outbreaks a considerable variation from the type 
has been noticed. Ascending myelitis, bulbar and pontine symptoms, 
encephalitis, cerebral ataxias, polyneuritis, meningitis, and even abortive 
forms are observed. 

Morbid Anatomy. — The microscopical appearances, as well as the 
finer changes, vary greatly with the age of the lesion. The early de- 
scriptions based on recovered cases were misleading. At the end of 
one or tiro months a focus or several foci of myelitis are found in the 
anterior gray. There is local destruction of nerve-tissue, with dilata- 
tion and changes in the vessels. The ganglion-cells of the anterior 
horn involved in the lesion have lost their prolongations, show granular 
disintegrations, or have entirely disappeared. The myelitic focus occu- 
pies one or both of the two arterial 
areas of the anterior horn; namely, 
that area supplied by the first branch 
of the anterior median arterv or 





Fig. 137. — Diagram of arterial 
mechanism producing infantile par- 
alysis (Williamson). 



Fig. 138. — Section of spinal cord in a case of 
acute anterior poliomyelitis of the adult, a, a, Dilated 
vessels surrounded by round cells (Williamson). 



that field supplied by the arteries which enter the cord along the anterior 
roots, or both. Rarely it extends backward in the middle arterial field 
and invades the neck of the posterior horn, and usually it embraces the 



1 "Jour. Exp. Med.," Oct., 1913. 

2 Flexner and Xoguchi, loc cit.; Amoss, 



'Jour. Exp. Med.," vol. xix, Xo. 2, 1914. 



LESIONS AND DISEASES OF SPINAL GRAY. 



391 



adjoining white matter of the cord to a varying extent. It is evident 
that the lesion is not strictly systematized, and it is equally evident that 
it is of vascular distribution. Batten 1 asserts, upon rather convincing 
evidence, that the vascular fault is primarily thrombotic, and that 
the lumbar cord is especially affected, owing to the circulatory disad- 
vantages of the part. Wickman 2 does not accept the thrombotic 
explanation, and probably, if such takes place, it is of secondary 
occurrence. 

Findley, Harbitz, and Scheel, 3 in the recent Norwegian epidemic, 
found a patchy leptomeningitis more evident on the anterior aspect of 
the cord and most severe over the areas of deeper-seated involvement, 
with great engorgement of the pia at these points. According to Flexner 





Fig. 139.— 1, Section of cervical cord in an old case of infantile paralysis. The right half is shrunken 
2, Lumbar section in a case of infantile palsy: a, Focus of old inflamma- 



in all its extent (Charcot) 
tion ; left half of cord shru 



ikeu. 



and his associates the special globoid bacteria can be demonstrated in 
the foci of inflammation. 

The myelitic foci vary in extent and number in various cases. Some- 
times they extend through several segments of the cord eight or ten 
centimeters or more in a vertical direction, but usually are one to two 
centimeters in longitudinal extent. Sometimes single, more frequently 
there are several foci either on the same or on opposite sides of the cord 
and at various levels. They may invade the medulla, and the brain 
is similarly involved in some cases that perish within the first few 
weeks. 

In cases of many years' standing the cord is seen to be shrunken on 
one side at the level of the lesion, and the cross-section is lacking in 
symmetry. The acute inflammatory condition has long disappeared, and 
a scar condition alone represents it. Nerve-fibers and cells are entirely 
destroyed. The absence of myelinated fibers renders the scarred area 
more or less glossy and translucent to the naked eye. The vessels are 
thickened and appear more numerous on that account. The shrinking 



1 "Brain," autumn, 1904. 

2 "Handbuch der Neurologie," Bd. ii, Lewindowski, Berlin, 1913. 



'Norsk. Mag. f. Laegevidensk.," 1907. 



392 DISEASES OF THE CORD PROPER. 

of the lateral half of the cross-section involves mainly the gray matter 
and especially that of the anterior horn, but the white columns and the 
posterior cornu may also share in it to 
some extent. If the original lesion is suf- 
ficiently extensive to involve the spinal 
apparatus of an entire extremitv, or even 




b 






Fig 140.— Case of poliomyelitis af- Fig. 141.— Case of poliomyelitis 

fectmg the lower extremities unequally ; affecting right face (rare), right arm, 

foot-drop on both sides. Note the wast- and shoulder, 
ing of the right leg and thigh. 

of a segment of it, changes in the cord above the lesion, and in the 
brain, are found analogous to those induced by amputations. 

The anterior roots arising from the injured part of the cord are often 
diminished in volume and may or may not show alteration of structure. 
This is true equally of the mixed nerve-trunks. The exact condition 
depends apparently upon the age of the lesion and the complete or 
partial disappearance of the peripheral prolongations of the spinal 
pyramidal cells that have been injured. In the paralyzed muscles we 
have the same changes that are found after division of the nerve-trunk, 
but a few muscular fibers often persist, some of which may even show 
hypertrophy. The rest of the muscle is fibrous and fatty. Infiltra- 
tion of fat sometimes reaches a condition that may properly be desig- 
nated lipomatous. The bones in the paralytic members are retarded in 
their growth, and in old cases dating from childhood are undersized in 
comparison with those of the sound side. They lack the sharply defined 
muscular markings, and the Haversian systems are found to be under- 
sized and poorly developed. 

Symptoms. — Usually without apparent definite provocation the 
child is found to be feverish and ill. A temperature of 100° to 102° F. 
has been frequently noted, and this febrile invasion stage lasts from a 
few hours to several days, when paralysis and flaccidity of one or more 
limbs are detected. It is not rare, however, for the child to go to bed 
apparently well and to awake paralyzed in the morning. The febrile 
movement may be attended by vomiting and diarrhea, by convulsions of 
a generalized character, or by delirium and diffuse cerebral manifesta- 
tions. As soon as the paralysis is noted, the case is usually recognized. 



LESIONS AND DISEASES OF SPINAL GRAY. 393 

Most writers state that there is a complaint of pain in the afflicted 
members only rarely, but that, as a rule, sensation in all its phases is 
entirely normal. It is probable, however, that early dysesthesia, owing 
to the usual infantile age of the patient and a lack of careful search 
for such difficulty, has been frequently overlooked. In some con- 
siderable number of cases handling of the affected limbs during the 
initial fever provoked outcries which were not elicited by similar 
manipulation of the other members. It is likely that more attention in 
this direction will show localized hypersensitiveness or some kindred 
state to be usually present and of diagnostic importance. Indeed, 
complaints of pain and of formication have been generally noted in 
older children and in adults, lending, perhaps, undue weight to the 
usual supposition that such cases are not of a true spinal type. In some 
cases there is even severe pain. The sphincters are seldom relaxed, so 
that control of the bladder and bowel remains unimpaired, but in the 
rare cases in which the sphincters are relaxed there is more or less 
apparent loss of sensation, the extent of the lesion is greater, and the 
prognosis is extremely unfavorable. 

Even in fat children the implicated muscles can be seen, after a few 
weeks, to have wasted, and if tested with the faradic current, either do 
not respond at all or show a remarkable diminution in their excitability. 
At this time the patient will have begun to show considerable improve- 
ment, the motor paralysis remaining complete only in the parts that 
are to suffer permanently, and a gradual improvement may be expected 
to extend over several months. In the muscles showing lessened 
faradic excitability galvanism commonly produces exaggerated responses, 
as compared with the sound limbs, and the complete reaction of 
degeneration or any modification of it may be encountered. In a well- 
marked case faradism fails by the tenth day, and the increased galvanic 
response appears, lasting for about six months, when it gradually declines. 
At this point faradic excitability returns and the muscle regains some- 
thing of its size and strength; or, if too seriously impaired, faradic 
response does not reappear, galvanic response disappears, and the muscle 
is irretrievably lost. 

The reflexes are lessened or abolished in proportion as the muscles 
which are anatomically associated with them are involved, or perhaps it 
would be better to say that their alteration depends upon the implication 
of the cornual cells making up a part of their arc. Bones which have 
not attained their full growth are retarded or entirely fail to develop if 
their trophic centers are implicated. 

The seriously atrophied muscles become fibrous bands, and, since they 
offer neither assistance nor opposition to the synergic and antergic mus- 
cles, distortions soon develop, with joint-changes and sometimes subluxa- 
tions. Joints which depend upon muscular support, as the shoulder, 
may allow of so much deformity by the relaxation of the muscles which 
have lost their tonicity that the articular surfaces widely separate. The 
skin is inactive, often cold, and sometimes dry and scaly, but the atrophic 
conditions so usual in neuritis are practically absent and bedsores are 
almost unknown. 

The lower extremities are affected about three times as frequently as 



1 



394 



DISEASES OF THE CORD PROPER. 



the upper, and the left leg twice as often as the right. A crossed form, 
in which the upper extremity on one side is involved with the opposite 
lower limb, is not rare ; but involvement of both limbs on the same side 
is extremely uncommon. In the lower extremity the extensors seem more 
susceptible than the flexors ; hence drop- foot, with talipes equinus, flexed 
knee, and flexed thigh are common. When the paralysis is below the 
knee, the sural muscles usually escape. In the upper extremity the most 





Fig. 142.— Deformity of foot after 
lumbar poliomyelitis acuta. 



Fig. 143.— Deformity of upper extremity and 
thorax after poliomyelitis anterior acuta. 



frequently encountered wasting is in the small muscles of the hands, the 
deltoid, and the extensors of the wrists. The biceps and supinators 
generally escape. 

The distribution of the paralysis of muscles follows their segmental 
relations in the cord, and, consequently, when limited is of a functional 
character. The very fact of such functional distribution at once incrimi- 
nates the cord. The muscles of the trunk are in rare cases notably and 
widely affected, producing weakness in the back, deviation of the spinal 
column, and defects in the muscles of the chest. Ordinarily, however, 
the segments of the cervical and lumbar enlargements are selected. A 
small focus of anterior poliomyelitis in the dorsal region hardly pro- 
duces local signs, as the trunk and thoracic muscles are represented in a 
considerable vertical extent of the cord. In rare cases, however, the 
abdominal or chest muscles or those along the spine are involved very 
decidedly. In a less degree this is not rare, as shown by spinal twists, 
protuberant abdomen, and abnormal respiratory movements of the 
thorax. 



LESIONS AND DISEASES OF SPINAL GRAY. 395 

The bulbar muscles do not always escape, as is shown by various 
ophthalmoplegias, squints, facial and hypoglossal palsies, which are now 
and then recorded, and would be more often seen did not coincident 
pneumogastric accidents usually terminate such cases fatally. 

Course and Forms. — The course of the disease may be clinically 
divided into : (1) A stage of febrile invasion, lasting from a few hours to 
several days, with local tenderness and rapidly developing and increasing 
paralysis ; (2) a stationary stage, lasting for several weeks ; (3) a period 
of improvement, lasting to the end of a year, and (4) a stage of 
permanent disability for the remainder of life. Relapses during the 
early weeks have been recorded in very rare instances, and second 
attacks are extremely rare. Among the sequelae the contractures, dislo- 
cations, and deformities have been already mentioned. The fragility of 
the bones makes them liable to fracture, but union takes place with ordi- 
nary promptness under proper fixation. 

The adult form is in no way different from the infantile cases, except- 
ing the variations due to complete growth having been attained. In 
anomalous cases the onset of the disease is insidious and the course may 
be subacute. After infectious diseases one or more limbs may be found 
useless, flaccid, and atrophic, declaring the antecedent myelitis. Occa- 
sionally the onset is marked by pains of a severe, cutting character, 
which are frequently attributed to neuritis or to rheumatism, but may 
be due to the irritation of the sensory pathway in the cord by the location 
of the myelitic focus backward, involving the neck of the posterior horn, 
or to an accompanying meningitis. 

An ascending form, presenting the clinical picture of a Landry's 
paralysis, is observed in some instances in almost every epidemic out- 
break, and many of the cases of so-called Landry's paralysis are undoubt- 
edly instances of poliomyelitis presenting an upward invasion course. 1 

It has been noted by a number of observers that in rare instances, 
years after the acute disease has subsided, a slow, insidious reappearance 
has led to a progressive muscular atrophy, w T hich declares itself first 
in the limbs that were originally paralyzed by the acute process. This 
may progressively invade the entire muscular system. 

Diagnosis. — In the early stages of fever, before paralysis has 
appeared, diagnosis usually fails except under rare epidemic conditions. 
The termination of an apparently trivial ailment in extensive paralysis 
is frequently the cause of much chagrin on the part of the medical 
attendant, who may naturally enough have expressed a favorable 
prognosis. As already indicated, the initial fever may be readily mis- 
taken for that of general disorders, and sometimes, though rarely, 
the pain in the limbs leads to the idea of rheumatism. If, however, 
the possibility of anterior poliomyelitis be in mind, and examination 
discloses some slight local tenderness or diminished muscular activity, 
or both, a guarded opinion will naturally follow. It is only when the 
paralysis is developed or developing that the nature of the disease 
becomes certain, and even then, if there have been cerebral symptoms, 
such as delirium or convulsions, difficulties are not at an end. The 
cerebral palsy of children is almost invariably ushered in by convul- 
1 Bassoe, "Transactions Chicago Path. Soc," Dec, 1908. 



396 DISEASES OF THE CORD PROPER. 

sions, but these have a definite distribution involving one side or one 
limb, or only the face, while the convulsions of the disease under con- 
sideration are generalized. Localized pain, from traumatism or inflam- 
mation, may cause immobility of a limb, and when preceded by fever 
gives rise to a doubt; but the usual absence of extreme sensory disturb- 
ances in disease of the anterior horns is a distinguishing feature, while 
the local conditions are usually marked by active muscular resistance. 
After a few days the electrical test gives absolute data. Faradic re- 
sponse is abolished in no other disease so early; even in severe neuritis 
it is longer maintained, and is then attended by a very marked sensory 
disturbance, which also usually precedes it for a long time. A few 
careful applications of the induced current at this period can do no 
harm. The progressive infantile myopathies are of extremely slow de- 
velopment and are symmetrical in distribution. Spinal puncture in 
the early stage yields a fluid containing the evidence of inflammation 
in lymphocytes and turbidity. 

Prognosis. — So far as life is concerned, this disease terminates 
fatally only exceptionally, and if the patient survives the onset of the 
paralysis but a short time, life may be considered out of danger. The 
danger is in direct relation to the involvement of the medullary func- 
tions, and is indicated by the presence of cranial nerve symptoms. 
Further, one can say, with a reasonable degree of certainty, that the 
paralysis at first developed will notably recede, but, unfortunately, it is 
almost equally certain that a portion of it will permanently remain. At 
the end of a fortnight a carefully conducted faradic examination of the 
muscles enables the physician to speak more specifically regarding the 
amount of permanent disability. At that time any muscle which re- 
sponds, however feebly, may be expected to regain a fair degree of its 
former tone and strength. Even after several months repeated faradic 
stimulation of a muscle, at first perfectly inactive, may develop some 
contractility, and this is of favorable import for the given muscle. The 
extent of permanent paralysis governs the amount of resulting contrac- 
ture and deformity ; and, likewise, the retardation of development of the 
limb and of the bones is in similar relation. The anticipated amount 
of these deforming conditions will have a bearing on the probable gen- 
eral activity of the individual, his prospective physical health, and lia- 
bility to fractures. The possibility of the late appearance of a progressive 
muscular wasting may be kept in mind. 

Treatment. — Every case should be treated as one of infectious or 
contagious character, with such measures to prevent dissemination as are 
usually employed in infectious and notifiable diseases. Owing to the 
irregularities of the course of this disease in various cases, and its nat- 
ural tendency to improve up to a certain point, it becomes a matter of 
great difficulty to estimate the value of any therapeutic agent or mode 
of treatment. In the early stage, as soon as the diagnosis is made, if 
fever still continues, there is good reason to suppose that antipyretic 
antiseptics, like the salicylates, large doses of the tincture of the chlorid 
of iron, or even bichlorid of mercury, would do good. The free use of 
urotropin is strongly recommended in the hope of producing an antiseptic 
effect in the spinal fluid and nerve tissues. Hot applications can be 



LESIONS AND DISEASES OF SPINAL GRAY. 397 

made to the spine if the circumstances of the patient will insure their 
intelligent and faithful employment; otherwise they are Avorse than 
useless. The child should be kept on the side or face, and the affected 
limbs should be thoroughly enveloped in cotton-wool to maintain the 
circulation and the nourishment of the muscles in the parts laboring 
under diminished trophic influence. There is hope that a specific 
antitoxin may be soon available. Even the use of antistreptococcus 
serum has some advocates. The use of spinal stimulants like strychnin, 
while the lesion is active, is to be avoided ; but when the active process 
has come to a standstill — that is, ordinarily, at the end of a fortnight — 
its svstematic use is one of the most important measures. The useful- 
ness of electricity consists of maintaining the nourishment and normal 
contractility of the muscles, which are temporarily deprived of their 
natural motor and trophic control, so that, as the inflammation subsides 
and the wide-spread inhibitory effect of the local lesion recedes, the central 
apparatus may find the muscular periphery in the most favorable state to 
respond to its enfeebled influence. For this purpose, as the faradic re- 
sponse is early abolished, the interrupted galvanic current must be used, 
the slightest intensity being employed that will cause a contraction. Care 
must be taken not to unduly fatigue the muscles. A dozen contractions 
at most should be elicited at one seance, and often only one or two can 
be provoked by any strength of current that is bearable. Care not to 
alarm the child is imperative, as a daily struggle will do more harm, 
probably, than the electricity will do good. As the muscles often 
react better and with less pain to the positive pole than to the negative, 
it is well to have for the negative electrode a broad sponge which may 
be placed on the sacrum or breast, and with a smaller, positive sponge 
the muscles may be exercised. Applications of galvanism through the 
cord are quite useless, and even if such currents reached the lesion, 
which is doubtful, their effect for good is questionable. 

Later on, as faradic response returns in the muscles only slightly 
affected or temporarily inhibited, this form of electricity is efficacious 
for the purpose of local stimulation, and the presence of this reaction 
in any muscle is always, as already indicated, a gratifying circumstance. 
To intrust galvanic electrical treatment to the parents, however intelli- 
gent they may be, is a mistake. 

In the same way local frictions and salt baths, warm wrappings, 
and massage are valuable measures which can be more rationally trusted 
to parents or nurses who take an intelligent interest in the work. They 
may be gently employed from the first day, and when electricity is not 
tolerated or can not be systematically employed, must be relied upon to 
replace it. The moment a group of muscles weakens, the limb tends to 
assume an abnormal position, and it is very important to meet this 
tendency from the very first moment, even in cases where there is every 
probability that the paresis will recede. It can be easily accomplished 
by means of the warm wrappings, or even by the application of light 
splints. There can be no question that recovering muscles will find 
their task much easier if their proper relations have been maintained. 
Unbalanced muscles will be much less liable to contractures if an arti- 



398 DISEASES OF THE CORD PROPER. 

ficial balance has been provided and joint-surfaces have not been altered 
by long-maintained vicious positions. 

As soon as the permanent paralysis can be fairly well foretold, 
massage should be especially directed to obviate the contractures and 
deformities that ordinarily result. Stretching of the unopposed muscles 
by passive movements of the joints will accomplish much, and the 
moment a tendency to contracture is perceived, the case becomes one for 
mechanical appliances. The tendency to talipes equinus, for instance, 
can be met by a light elastic cord from the toe of the shoe to a band at 
the knee ; and more elaborate orthopedic apparatus should be employed 
at the knee and hip if required. Two important points should guide 
the treatment of the paralyzed parts : first, never to permanently im- 
mobilize any joint or muscle that has a particle of voluntary power; 
second, to persist with gentle massage, light supports, and re-educational 
exercises if need be for years. 

Nearly all the improvement that is to take place in the muscles 
will have developed by the end of the first year, and what is slowly 
subsequently gained is usually dependent upon continued massage, 
exercises, and similar local measures. 

The treatment of a late or neglected case is practically surgical. 
Shortened tendons may be cut and joints straightened. Tendons of 
healthy muscles may sometimes be transplanted to take the place of 
those paralyzed. Much is being accomplished by nerve suture. The 
involved nerves are being grafted into sound ones and the innervation 
of the atrophic area re-established. A resection at the knee is some- 
times of advantage to secure a rigid limb instead of a useless contortion 
or a dangle-leg. By using a high shoe or other appliance crutches may 
often be laid aside. 

SYRINGOMYELIA. 

The central canal of the cord is sometimes enlarged through congenital 
defect. This may be a part of a general ventricular distention, causing 
hydrocephalus and spina bifida. In certain instances unattended by any 
symptoms during life a tubular cord has been found post mortem. These 
cases present hydromyelia and are of teratological origin. The term 
syringomyelia is now limited to acquired enlargement of the central 
canal or to the formation of entirely new canals of considerable length 
in the gray substance of the cord. Such canals are the result of glio- 
matous infiltration about the central canal or in the gray horns of the 
cord and its subsequent degeneration, forming tubular, cystic cavities. 
In rare instances a central myelitis or a central hemorrhage may cause 
a fusiform or tubular excavation that can not always be clinically dis- 
tinguished from the neoplastic variety or may in turn induce the latter. 
Some cases probably originate in spinal hemorrhage occurring at birth. 
This disease, considered rare in the nineties, is now frequently recog- 
nized, and in neurological clinics furnishes about the same percentage 
of patients as infantile cerebral palsy. 

Etiology. — Men are much more frequently affected by this disease 
than women, and especially men exposed to hard labor. Verhagen and 
Yandervelde report several instances of syringomyelia in the same family, 
but a neuropathic heredity is rare. Adult years furnish nearly all the 



LESIOXS AND DISEASES OF SPIXAL GRAY. 



399 



reported cases, but it has been observed well developed at nineteen by 
Langdon, of Cincinnati, by the author at sixteen, and by Ballard and 
Thomas at three. 1 Cold, rheumatism, exposure to bad weather, trau- 
matism, overwork, the acute infectious fevers, and syphilis, 2 have been 
reported as possibly causative in various cases, but this relation, in the 
gliomatous form, at least, is entirely conjectural. 

Morbid Anatomy. — The syringomyelic cord in marked cases shows 
notable changes of conformation that correspond to its tubular condi- 




Fig. 144.— Sections of a syringomyelic cord. 1, Lower lumbar region ; 2, upper lumbar region- 
3, midcervical region (Bruhl). 




Figs. 145 and 146. — Sections of two syringomyelic cords snowing common locations and extent of 

cavities (Brissaud). 



tion. It is soft, flattened, and sometimes fluctuating. The collapse of 
the canal may produce a furrow, so that the cord seems double. The 
condition finds its favorite locality in the cervical region, but may extend 
throughout the entire length of the cord or be confined to any portion of it. 
Its upward extension carries it into the fourth ventricle. According to 
Haenel, 3 medullary participation is found in about one-third of all cases. 
The cross-section usually reveals a single oval cavity, or there may 
be several in communication or independent. The customary situation 

1 "Am. Jour. Med. Sci.," March, 1899. 2 Nebelthau, "Zeit. f. Nervenh.," Feb., 1900. 
3 Lewendowsky, "Handbuch der Neurologie," Band II, S. 58-4, 1911. 



400 



DISEASES OF THE CORD PROPER. 




is in the immediate neighborhood of the central canal and behind it, 
but it may extend laterally into the anterior or more commonly into the 
posterior horn of gray matter, either on both sides or unilaterally. 
Again, it may be limited to one posterior horn. While the white columns 
of the cord may be spared, it is not unusual for the gliomatous process 
to invade them, especially the pyramidal tract, when the gray matter 
has been widely destroyed and the cavity has attained large proportions. 

The cavity contains cerebrospinal fluid, which 
is sometimes bloody or gelatinous. Its walls are 
made up of a well-defined substance, outside of 
which the cord appears infiltrated, dense, and even 
sclerosed. In the medulla, when the lesion extends 
so high, the gray matter is first similarly affected. 
The microscope shows the usual new formation 
to be gliomatous and rich in blood-vessels, especi- 
ally on the external periphery. The predomi- 
nance of various elements gives rise to varieties 
such as pure glioma, neuroglioma, and vascular 
glioma, all of which may be present in the same 
cord. Schultze describes an infiltrating sort as a 
gliosis. It does not usually result in cavity form- 
/ ation, and is, therefore, distinguished from the 

/ ^ \ gliomatous variety. He is supported by Hoffman, 

I L and Holt and Harter x report a case. Orlowski 2 
V m \ has seen a double canal, one arising from dilatation 

\8 t of the central canal and the other from gliosis and 

degeneration outside the central canal. Charcot, 
B ^ Hollopeau, Joffroy, and Achard insist that in some 

cases the initial step is a central myelitis, which 
1 Schultze, Dejerine, and others deny. The nerve- 

tissues involved in these various processes are 
strangled and destroyed even before the formation 
Df cavities. The cells first yield their prolonga- 
tions and then disappear. The axis-cylinders out- 
last the myelin. The meninges and spinal roots 
: are usually unaffected except in the form associ- 
ated with cervical pachymeningitis. Destruction 
of the anterior horns is followed by the usual 
trophic disturbance in the associated periphery, 
such as wasted muscles, perforating ulcers, and 
cutaneous dystrophy. The interference with the cells of Clarke's columns 
is supposed to account for the joint-lesions that are commonly present, 
and which are identical with the arthropathies of locomotor ataxia. 

Symptoms. — From the nature of the lesion it is apparent that the 
symptoms may in different cases embrace perversion and obliteration of 
all the various functions of the cord. Nevertheless, their peculiarities 
and groupings are sufficiently distinct to frequently enable a diagnosis. 
As there is no common type, the symptoms must be arranged somewhat 
arbitrarily. 

1 -'Am Jour. Med. Sci.," April, 1895. 2 "Arch, de Neurol.," Sept., 1898. 



Fig. 147. — Case of syrin- 
gomyelia with areas of 
thernio-anesthesia marked 
in black. There is cervical 
kyphosis. 



LESIONS AXD DISEASES OF SPIXAL GRAY. 



401 



Sensory Disturbances. — The early involvement of the sensory path- 
ways in the gray commissure and in the posterior horns and columns 
produces related sensory symptoms which are well-nigh characteristic. 
There are usually definite practically coextensive areas of thermo- 
anesthesia and analgesia, with retention of the tactile sensibility. This 
is sometimes denominated the syringomyelic dissociation of cutaneous 
sensation, and is highly important to the diagnosis. The patient fails 
to distinguish the temperature of water or objects brought in contact 





Fig. 148.— Various distributions of therruo-anestbesia and analgesia (Brissaud). 

with the skin, though recognizing contact, and may receive burns in this 
way without experiencing any pain. The thermo-anesthesia may be 
complete or partial, and is then relative to the part examined and some- 
what to the patient's intelligence (see Part I). Sometimes heat is felt 
as pain, or " hot " as " cold," and all possible variations of degree, and 
confusion may be encountered, including well-marked anaesthesia dolo- 
rosa. The distribution of the thermo-anesthesia is also significant. 
Rarely it may be hemiplegic ; it is seldom general. Ordinarily, it in- 
volves the limbs, or portions of them, such 
as would be covered by a glove or sleeve, a 
sock or long stocking. It may be limited 
to thoracic or abdominal bands or stripes 
along the limbs. It may be unilateral or 
symmetrical. In figure 147 it is of un- 
usual outline, but will be noticed to 
roughly conform to some spinal segments. 
In some cases areas at first discrete have 
been observed to coalesce into anatomical 
cord-territories. The mucous surfaces are 
similarly affected. 

The analgesia may be partial or com- 
plete, and usually conforms in outline in 
a general way to the thermo-anesthetic area, or it may be more extensive. 
It embraces all the tissues,- so that felons, caries of bone, and disinte- 
grating joints may be painless and insensitive. 

As a general rule, tactile or epicritic sensibility is perfect. A slight 
diminution of it is not inconsistent with the diagnosis, and its oblitera- 
tion follows extreme invasion of the posterior columns, being then a 

26 




Fig. 149. — Thermo-anesthesia and aual 
gesia (Brissaud). 



402 



DISEASES OF THE CORD PROPER. 



* 



part of the absolute anesthesia that marks such a lesion. An anesthetic 
area may thus have a border of thermo-anesthesia and analgesia, or these 
conditions may be found in different parts of the body, in relation to 
the amount and distribution of the cord disease. In some cases and at 
early stages pains of a tabetic, neuralgic, or burning sort are persistent. 
Other patients complain of a constant warm or burning sensation in a 
given region. As a general rule, deep or protopathic sensory features 
are more involved than the superficial or epicritic. Thus, sensitiveness 
of joints of the testicle and eyeball is often blunted or abolished. 

Motor disturbances are dependent largely upon the invasion of the 
anterior horns and the pyramidal tracts. They are, therefore, usually 
secondary in point of time to the sensory symptoms with which they come 
to be associated. As the anterior horn is invaded, the associated muscles 
lose power and their reflexes diminish and disappear. Some muscular 
atrophy is almost always present, and it may reach a high grade. Its 
distribution depends upon the part of the cord involved, and may con- 
form to many of the typical spinal atrophies, such as the form of 
Duchenne-Aran, for which it has no doubt been frequently mistaken. 
It may be progressive or advance by spurts, and is most common in 

the upper extremities. Fibrillary twitch- 
ing and reaction of degeneration mark the 
atrophic muscles, as in other muscular 
atrophies of spinal origin, and their 
strength is reduced in proportion to the 
atrophy. When the gliomatous process 
invades the lateral tract, spastic features 
are induced. These may be associated 
with disorders due to involvement of the 
anterior horn, producing the conditions 
found in amyotrophic lateral sclerosis, but 
the face is usually unaffected. Involve- 
ment of the posterior columns causes 
ataxia and incoordination. Tremors, 
cramps, fibrillation, choreoid movements, 
and various muscular twitchings are not 
infrequent. 

Trophic Features. — The affected ex- 
tremities, in addition to the muscular 
atrophy, often present trophic disturb- 
ances, especially about the digits, similar 
to those in neuritis. Glossy skin, hyper- 
trophic nails, increased or diminished per- 
spiration, and herpetic and bullous erup- 
tions are encountered. Cuts, burns, and 
abrasions heal badly or tend to permanent 
ulceration. In this way paronychia causes 
the nails to fall. Felon is rather com- 
mon, especially in the Morvan type, and 
causes mutilations of the fingers by the loss of several phalanges, un- 
attended, usually, by the slightest pain. Perforating ulcer is encoun- 



1 




Fig. 150.— Case of syringomyelia, 
showing atrophy over right scapula 
and thorax and in right leg. Spine 
scoliotic. 



LESIONS AND DISEASES OF SPINAL GRAY. 



403 



tered with some frequency. Boils, abscesses, and other local infections 
are not rare. They all heal badly, produce extensive scars, and may 
cause mutilations and deformities. A thickening and hardening of the 
skin, especially of the fingers, is common, and variations of Raynaud's 
syndrome are often added. 

The arthropathies are almost invariably represented. They aifect 
the spine by preference, and the articulations of the upper extremities 
more frequently than those of the lower limbs. In some cases the 
bones are affected. They are fragile, readily fractured, and unite with 
difficulty and with persisting callous deformities. In a few cases the 
hands have been enlarged, as in acromegalia, for which this disease has 
been mistaken. They have even been found associated. The spinal 
arthropathies give rise to deviations of the vertebral column in over 
one-half of the cases. Usually it is a scoliosis, but angular deformities 
are not infrequent. The muscular weakness may account for some of 
the spinal deformities. A deep cavity at the upper portion of the 
chest in front has been noted several times by Astie * and Schrader has 
reported two cases presenting habitual dislocation of the shoulder due 
to changed contours of the humeral head and the glenoid cavity. 

Vasomotor symptoms are represented by dermographia, blueness 
or redness, edemata, and localized disturbance of perspiration, especially 
in the affected areas. 

Unusual Symptoms. — In various rare instances the following 
unusual and rather accidental conditions have been present, due to the 
special location of the gliomatous disease in the particular case : Loss 
of sphincter control, sexual impotence, suppression of menstruation, 
pupillary inequality, narrowing of the palpebral fissure and retraction 
of the eyeball, nystagmus, facial paralysis, hypoglossal paralysis, optic 
neuritis, pneumogastric accidents, glycosuria, polyuria, and pronounced 
bulbar invasion, producing a progressive bulbar palsy and other cranial- 
nerve disablements. Such cases are sometimes designated syringobulbia 
(Fig. 152). 

Course. — Syringomyelia is a chronic malady of slow progression 
and fatal termination. It often presents stationary periods 




Fig. 151. — Hands and foot in cases of syringomyelia of Morvan's type, showing, 1, mutilations of the 
fingers from whitlows, 2, osteo-arthropathy of wrist-joint, and 3, loss of toes. 



or even slight temporary improvement may be noticed. Bulbar invasion 
means early termination. It has exceeded forty years' duration in 
favorable cases, and may be interrupted by death from concurrent or 

1 "These de Paris," 1897. 



404 



DISEASES OF THE CORD PROPER. 



accidental disease. Its logical termination is in death by exhaustion or 
by bulbar crises. Ulcerations, dystrophic conditions, or infections from 
such sources may induce a fatal termination. 




Fig. 151, a. — Charcot wrist- joint in syringomyelia. 



Clinical Forms. — The ordinary form has been in view in the pre- 
ceding lines. One clinical variety is furnished by Morvan's disease. In 




Fig. 151, b. — Skiagram of joint shown in Fig. 151, a. 



this form the sensory dissociation is marked, especially in the hands and 
arms, with associated atrophy and paresis. There are mutilations of 
the fingers by successive whitlows and marked cutaneous dystrophy. 
Scoliosis and arthropathies are usually present. Zambaco insisted that 
this is a form of leprosy, and Prus * demonstrated in such a case a 
bacillus closely resembling that of leprosy. On the other hand, Joffroy 
and Achard have demonstrated central cord-cavities in Morvan's dis- 
ease, and this is confirmed by Thomas. 2 The leprosy idea can no longer 
be entertained. In both a peripheral neuritis is common, and Prus 
suggested that the propagation of the leprous bacilli in the cord might 
furnish the irritation that incites the gliomatosis. 

There is more than an accidental relation between syringomyelia 
and a cervical hypertrophic pachymeningitis. Brissaud 3 insists that the 
meningeal process usually precedes and furnishes the irritation that sets 

1 "Lecons sur les Maladies Nerveuses," 1895. 

2 "Archiv f. Psychiatrie," Bd. xxvii. 3 "Rev. Med. de la Suisse Remande." 



LESIONS AND DISEASES OF SPINAL GRAY. 



405 



up the central gliomatosis. It seems probable that any permanent cord 
irritation may lead to a secondary syringomyelia. 

Prognosis.— The outlook in any given case is ultimately fatal, but 
the duration of the disease must be estimated by the course it is running 
and the portions of the cord affected. Bulbar symptoms are extremely 
grave and lumbar involvement is hardly less so. The tendency to sta- 
tionary periods and slight remission must, however, be kept in mind. 





Fig. 152. — A case of syringomyelia with involvement 
of face and tongue — syringobulbia. 



Fig. 153. — Syringomyelia with much atropby 
and spinal deviation. 



On the other hand, hemorrhage in the gliomatous area is rather common 
and causes initial symptoms, serious complications, and fatal effects. 

Diagnosis. — The diagnosis depends upon the insidious develop- 
ment of the disease and upon the combination of sensory, trophic, and 
motor disorders. The dissociation of touch and pain is well-nigh dis- 
tinctive, but is occasionally found in tabes, neuritis, and hysteria. 
Usually it will be necessary to exclude progressive muscular atrophy, 
amyotrophic lateral sclerosis, pachymeningitis hypertrophica cervicalis, 
Pott's disease, cervical ribs, locomotor ataxia, and peripheral neuritis. 
Perhaps acromegalia, scleroderma, leprosy, and hysteria may at times 
confuse, but in all these an attentive study of the combinations of 
symptoms should enable a diagnosis to be made. 

Treatment has proved futile, or nearly so. Measures looking to the 
general well-being of the patient are most advisable. Locally, massage 
and electricity may give slight help at times. Counterirritation over the 
spine must be used with caution, as it is capable of producing extensive 
and rebellious ulceration It is possible that .r-ray applied along the 
spine in the region of the gliosis might retard the neoplastic activity, 
and some favorable cases have been reported. When it is possible to 
diagnose a pachymeningitis or to localize the gliosis in a limited verti- 



406 DISEASES OF THE CORD PROPER. 

cal cord area, surgery holds some promise of amelioration. It is prob- 
able that some of the intramedullary spinal tumors that have been 
operated upon, and occasionally with success, are of this character. One 
operation done for me in a well-marked case of cervical syringomyelia 
resulted in the removal of the intramedullary growth and very great 
improvement. 

The patient must be warned to avoid the ever-present danger of 
burns and infections, against which he is no longer guarded by normal 
sensibility. Muscular strain may precipitate hemorrhage into the 
gliomatous tissue, with very serious or fatal results. For the neuralgic 
pains and occasional cramps various analgesic and quieting remedies 
may be employed, but with preference for the milder and habit-free 
drugs. Warm baths and hot applications usually answer the purpose. 

PROGRESSIVE MUSCULAR ATROPHIES PRESENTING LESIONS OF 
THE SPINAL GRAY MATTER. 

All progressive muscular atrophies may be divided into those in 
which (1) lesions of the spinal gray matter are found, and (2) those in 
which no such changes are discoverable by our present means of investi- 
gation. It may at once be admitted that this division is arbitrary and 
probably temporary. It is not unlikely that many members of the 
second group will eventually be found in the first. The present con- 
ception of the integral character of the lower motor neuron, embracing 
the spinal pyramidal cell, its peripheral prolongation, and the muscular 
organ under its motor and trophic domain, is inconsistent with the idea 
that the so-called muscular dystrophies or idiopathic muscular atrophies 
are independent of disturbance in the spinal gray. For purposes of 
convenience they will be separately described, though every gradation 
is found from first to last, and even a single case may present several 
of the varieties at one or in successive periods. 

Duchenne, followed closely by Aran, in 1849 and 1850 described 
a progressive muscular wasting without sensory disturbance, which they 
called progressive muscular atrophy and thought it a disease of the 
muscles. Cruveilhier, in 1855, recognized it as a spinal disease, and 
Lockhart Clarke first limited the lesion to the anterior spinal gray 
matter. Charcot still further differentiated the lesion and pointed out 
its dependence upon degeneration of the ganglion-cells of the anterior 
horn. Later on Charcot distinguished a variety of progressive mus- 
cular atrophy in which the lateral tracts were also degenerated, and 
called it amyotrophic lateral sclerosis. The first variety is now called by 
French writers Duchenne- Aran' s disease, the second, Charcot's disease. 
Of late, some writers, notably Marie, have tended to deny the existence 
of the Duchenne-Aran typ@ in toto. Others, as Gowers, insist that both 
the Duchenne-Aran type and the type of Charcot are identical, only 
varying as the lateral tracts or the anterior gray — that is, as the upper 
or lower motor neurons — are first or most degenerated. Gowers states 
that he has never seen a case in which lesions in both spinal regions 
could not be detected, and cases presenting lesions confined absolutely to 
the anterior gray no longer appear in current literature. Many cases 



LESIONS AND DISEASES OF SPINAL GRAY. 



407 



formerly classed with the Duchenne-Aran type were doubtless those 
of multiple neuritis, syringomyelia, Charcot's disease, and the so-called 
idiopathic muscular atrophies to be later described. More recently 
Hoffman, 1 Eulenberg, Daehnhardt, Dubreuihl, and Long 2 have reported 
cases clinically indistinguishable from the spinal type of Duchenne, but 
presenting neuritic lesions only. We may, therefore, properly discard 
many of these conflicting terms and speak of progressive muscular 
atrophy with or without cord lesions. 

Attention is now directed to the first sort, which embraces conditions 
variously called spinal progressive muscular atrophy, wasting palsy, 
chronic poliomyelitis, amyotrophic lateral sclerosis, atrophia muscularis 
progressiva spinalis, Duchenne's disease, and Charcot's disease. 

Etiolog-y. — Progressive spinal muscular atrophy is practically a dis- 
ease of adult life occurring between the ages of twenty-five and fifty, but 





Fig. 154. —1, Normal anterior horn ; 2, anterior horn in a case of amyoti'Ophic lateral sclerosis (Marie). 



it may appear earlier or later. It is somewhat more frequent in men than 
in women. Direct inheritance is very rare, but a neuropathic tendency 
can occasionally be traced. It has been noted as following various 
alleged vague causes, such as anxiety, overwork, exposure to cold, con- 
cussion of the spine, syphilis, and various infectious and septicemic states. 
Its appearance years after an acute poliomyelitis has been already indicated 
under that caption. A close inquiry will sometimes detect a history of 
symptoms antedating the alleged cause. There can be little doubt that 
at least in some instances it is an expression of teratological defect in the 
motor and trophic portions of the central apparatus, and constitutes a 
primordial shortcoming by which these parts reach an early death. 
Since the Wassermann and spinal fluid tests have been available, posi- 
tive findings in these cases indicate that syphilis is a more common 
feature, if not an actual cause, than was formerly supposed. 

Morbid Anatomy. — The lesions of progressive spinal muscular 
atrophy embrace in rare cases the entire motor field of the nervous 
apparatus from cerebral cortex to muscular nerve-endings, and include 

1 "Neurolog. Centralbl.," 1889. 

2 "Nouv. Icon, de la Salpet.," 1912. 



408 



DISEASES OF THE CORD PROPER. 



the muscles themselves. Both upper and lower motor neurons in their 
entirety are destroyed by a degenerative process. Following the patholog- 
ical rule that a neuron degenerating from toxic cause or involution first 
shows changes in its peripheral portion, the upper motor segment may 
present alteration only in the pyramidal fibers of the cord. This may 
reach the medulla, and, as a rule, does not extend into the peduncles, 
capsule, and cortex, though it may do so. In the lower neuron the de- 
generation is probably at first peripheral, but in all cases that reach a 
marked development the cells of the anterior gray are found degener- 




Fig. 155.— Cord-sections in a case of amyotrophic lateral sclerosis. 1, Lumbar region ; 2, dorsal region ; 

3, cervical region (Marie). 

ated. Attending this we have muscular atrophy, with fibroid and fatty 
changes and degeneration in the motor fibers of the nerve-trunks, limited 
sharply by the anatomical relations of the diseased cord-elements. 

In the cord the gray substance of the anterior horns shows atrophy. 
The ganglion-cells, many of which usually have disappeared, are wasted 
and degenerated, and there is a general shrinking of all the nervous ele- 
ments of the horn. The white substance of both the direct and crossed 
pyramidal tracts shows sclerotic degeneration. This process is not 
strictly confined to them, but usually involves the anterolateral tracts to 
a lesser degree, and may invade the lateral limiting layer. This is espe- 
cially the case in the upper dorsal and cervical regions. The columns 
of Goll sometimes show slight changes, apparently due to the shrinking 
of the myelin, and not to an active degeneration. The lesions of the 
anterior cornua are generally most pronounced above the dorsal region, 
but the involvement of the crossed pyramidal tracts extends to the lowest 
cord-levels. Similar changes may be traced through the medulla, both 



LESIONS AND DISEASES OF SPINAL GRAY. 



409 



in the gray matter below the fourth ventricle and in the pyramidal 
tracts above the decussations. These latter may mount through the 
peduncles and internal capsules to the pyramidal-cell layers of the cortex, 
and there a cellular degeneration, identical with that in the spinal gray, 
may occasionally be encountered. 

The muscles are pale and fatty, and under the microscope present 
various changes. The fibers may be narrowed, with striae poorly 
marked or less frequent than in health, or more frequent and deeply 
marked, showing a tendency to fissuration. The striation may entirely 
disappear in fatty granulations, and distinct globules or the empty sar- 
oolemma sheaths may alone remain. Longitudinal striation sometimes 
develops, and the transverse markings may later disappear. The 
nerve-trunks often contain degenerated fibers, which can be traced 
through the anterior spinal roots to the anterior horns. All these cen- 
tral and peripheral changes vary in degree in different cases, and inter- 
mediate instances are becoming more and more frequently noted in 
which the muscles or the nerve-endings or the anterior cornual cells 
show preponderating changes. Only the most approved technic can 
be relied upon to determine minor abnormalities. 




Fig. 156. —Hand in advanced case of amyotrophic lateral sclerosis, showing muscular wasting and the 
characteristic ape position of thumb. 



Symptoms. — The various types of spinal muscular atrophies and 
the confusion that has arisen over them, as well as the symptoms in 
various cases, are referable to the vertical extent of the lesions and 
the varying intensity of the process at different levels. It must at 
once be evident that if the degeneration falls first on the lower neuron, 
flaccid, atonic, atrophic paralysis will appear in the periphery. On the 
other hand, if the upper neuron be primarily affected, the paralytic 
state will be spastic and the tonic atrophy will be marked by rigidities. 
All degrees between these extremes are encountered in practice. Flac- 
cidity may be present in the upper and spasticity in the lower extrem- 
ities in the same case. Involvement of the upper neuron can only be 
evidenced through the lower in the way of increased reflexes and spas- 
ticity. If, then, the lower neuron leads the upper in the degenerative 



410 



DISEASES OF THE CORD PROPER. 



course, the latter can not produce its signs. Again, the degenerative 
process falls by preference on the cervical cord and manifests itself in 
the upper extremities first. Thence it tends to extend, and eventually 
reaches the cranial nuclei in the bulb, inducing a progressive bulbar 
palsy. In other cases the higher levels are first affected, presenting 
bulbar palsy or ophthalmoplegias, and the downward extension of the 
disease may be cut short at any point by pneumogastric accidents. 
Labiolinguopharyngeal paralysis or bulbar palsy is apparently identically 
the same disease first affecting the bulbar centers. It is also variously 
combined with the spinal forms. (See page 159.) 




r 






Fig. 157.— A case of progressive muscular atrophy of the spinal type in the sixth year of the 
disease. All skeletal muscles affected. 



The muscular atrophy and weakness usually come on together and 
progress equally. In the great majority of cases wasting appears first 
in the radial half of the hands, sometimes first in one hand, sometimes 
in both hands at once. In another group of cases the shoulder-muscles 
are first affected. In the hands the disease ordinarily affects first 
the thenar muscles. It, therefore, appears to elect those muscles which 
show the highest differentiation of function and which represent the 
latest motor acquirements in the evolutionary scale, — namely, circum- 
duction of the upper limb and the opposition of the thumb to the 
fingers. If the morbid process be one of involution, we might naturally 
expect such a program. It results in flattening the palm, and the 
thumb falls back into the same plane with the other digits, producing 



LESIONS AND DISEASES OF SPINAL GRAY. 41 1 

the "ape hand" (Fig. 156). The interossei and lumbricales are also 
affected, and again most on the radial side of the hand. Furrows 
between the metacarpals mark the loss of the small muscles, and the 
integument hangs loose and redundant with numerous folds and 
wrinkles. The bones are entirely denuded of muscular covering in 
severe cases. A persistence of subcutaneous fat sometimes obscures 
the muscular atrophy. In late cases there is a marked tendency to 
clawing of the fingers, from the involvement of the small muscles, so 
that the first phalanges are extended, the second and third sharply 
flexed (Fig. 156). They may be rigidly and spastically fixed, all vol- 




~ 



Fig. 158.— Hand in early amyotrophic lateral sclerosis, showing excavation of the interosseous spaces and 

flattening of palmar eminences. 

untary motion destroyed, and passive motion much limited. The mus- 
cles of the forearm suffer next, or they may escape for a time and the 
shoulder-muscles waste first. In other cases the muscles of the neck 
are first involved, and then those of the upper extremity, or the wasting 
may even develop first in the legs or buttocks. Muscles like the pectoralis, 
deltoid, and trapezius, which have different associations, and receive their 
innervation from different spinal levels, may waste in corresponding por- 
tions. It thus happens that the upper portion of the trapezius is fre- 
quently spared until late in the disease, as it is controlled by the spinal ac- 
cessory. Again, it may suffer early. The muscles of the back are among 
those early invaded, and those of the scapula are commonly first 
affected, allowing corresponding displacements of this bone and limit- 
ing the use of the arm. The thoracic muscles are also involved, 
impairing respiration, and if the abdominal groups suffer, breathing 
may become purely diaphragmatic. Wasting in the legs is much less 
common and is usually less in degree, though atrophy may here first 



412 DISEASES OF THE CORD PROPER. 

show itself. In the same way the face escapes for a time, or the dis- 
ease may commence in the bulbar nuclei, and labioglossopharyngeal 
palsy may be the first step toward generalized progressive muscular 
atrophy. Finally, no voluntary muscle may escape. 

The muscular wasting and loss of power result in corresponding 
changes of contour and position deformities. The patient may be 
unable to hold the head erect. The uncovered acromium renders the 
shoulder angular. The claw-hand, the scoliotic spine, the displaced 
scapulae, and the distorted chest manifest the unsupported skeleton. 
The characteristic of the atrophy is its gradual invasion of a muscle 
fiber by fiber, commonly preceded by fibrillary twitchings. These 
twitchings are sometimes decidedly exaggerated, causing arhythmic jerk- 
ing movements of the hands and arms or twitchings of facial muscles. 

The reflexes may be either abolished or more commonly increased in 
activity. Early and rapid wasting is often marked by diminution and 
even extinction of the reflexes in the affected muscle ; but, again, there 
is often early rigidity and marked myotatic irritability, which last 
throughout the disease and persist even when the muscles are much 
wasted; or reflexes at first exaggerated may disappear. The reason for 
this variability has been already indicated. 

In the lower extremities, however, it is the rule that the reflexes are 
augmented and spastic disturbance of a paraplegic sort is commonly 
found unless the atrophy begins in the lower members. This gives rise 
to the spastic gait often marked by clonus and dragging footsteps. The 
rigidity may show itself by the fixity of position, even when the patient 
is seated or in bed. The legs tend to extension, the arms to demiflexion, 
and the hands are held in the negative position, midway between pro- 
nation and supination. The sphincters are seldom affected. An exces- 
sive jaw-jerk can sometimes be elicited, and implies bulbar extension of 
the disease. The cutaneous reHexes are normal so long as their muscles 
survive the atrophic invasion. 

The bulbar symptoms of the disease correspond to those of bulbar 
palsy (see p. 159). Fibrillary twitchings about the mouth and eyes 
and in the tongue are followed by wasting, and the characteristic facial 
expression is developed. In advanced cases the open mouth, the 
druling saliva, the difficulty of deglutition, the nasal voice, and the 
pneumogastric palsies only too plainly indicate the upward extension of 
the disease and the critical condition of the patient. The pharyngeal 
reflex usually persists as long as the pharyngeal muscles have power to 
act. The mind is not disturbed. 

The electrical response in nerves and muscles is, as a rule, quantita- 
tively reduced for both currents, and finally extinguished. In a rough 
way it is proportionate to the amount of muscular fiber present. In most 
instances the reaction of degeneration is found in a few muscles, or any 
variation of it may be presented. 

Sensibility is practically intact. In some instances there is complaint 
of dull pains at or before the onset of atrophy, and vague feelings of 
weakness, fullness, and formication may be mentioned during the disease. 
The paralytic and wasted limbs are usually cold and the circulation is 



LESIONS AND DISEASES OF SPINAL GRAY. 413 

poor, but trophic disturbance in the skin, perforating ulcers, arthrop- 
athies, and bedsores are unknown. The visceral functions are not 
notably impaired. 

Varieties. — The chief varieties to be distinguished are : First, cases 
marked by flaccid, atonic atrophy, which reaches an extensive degree, 
usually first appearing in the small muscles of the hands, — the Duchenne- 
Aran type ; second, cases marked by similar wasting, but less in degree, 
and presenting tonicity, rigidity, and increased reflexes from the first, — 
amyotrophic lateral sclerosis, or Charcot's disease ; third, an intermediate 
variety with only slight muscular wasting, but with great weakness and 
with spasms and retained reflexes ; fourth, the variety beginning as a 
labioglossopharyngeal paralysis, an ophthalmoplegia, or some bulbar palsy. 

Course. — These spinal muscular atrophies may commence in 
'various ways and first invade any portion of the cord or the bulb. 
The clinical course varies accordingly. It is, however, progressive, 
and may terminate in a few months or a year, or consume twenty or 
thirty years in its evolution. Apparently stationary periods in the 
protracted cases are not uncommon, but the logical termination in all is 
death from cardiac or respiratory failure. Intercurrent disease, espe- 
cially acute infections and particularly pneumonia, are badly borne and 
frequently end life. 

Diagnosis. — In fully developed cases of the spinal progressive 
atrophies the diagnosis is usually not difficult, but a differentiation from 
the so-called idiopathic muscular atrophies of the next section may 
sometimes be impossible. AVe rely upon the presence of fibrillary 
twitching, increased reflexes, if only in the legs, and the reaction of 
degeneration in at least some of the muscles, to indicate the spinal 
location of gross changes. These cases usually begin in adult life and 
show no particular family history ; the second group usually begin in 
childhood and are frequently familial. The spinal varieties select the 
muscles of the hands, shoulders, or lips first ; the idiopathic varieties 
commonly spare the hands at first and may select the humeral muscles 
or the peroneal group first, and are frequently marked by pseudohyper- 
trophies, especially of the calf, gluteal, and scapular muscles. Multi- 
ple neuritis ordinarily affects all four extremities and can be traced to 
some competent infection or poisoning. In it the sensory symptoms are 
prominent from the first, while they are slight or absent in spinal 
myopathies. Syringomyelia may produce a local atrophy, but has its 
distinctive index in the dissociation of cutaneous sensations and the 
usual presence of arthropathies and other trophic disorders, besides 
usually being unsymmetrical. Multiple arthritis is sometimes marked 
by extreme muscular atrophy. Here we have the early history of 
articular disease and the continued existence of arthritic mischief. 
The wasting, too, is usually on the proximal side of the joints, thus 
sparing the small muscles of the fingers. It is as likely to appear in 
the lower as the upper extremities, is rarely accurately bilateral, and 
affects first and principally the joint extensors. The reflexes may be 
increased, if not inhibited by pain or ankylosis, and the faradic 
irritability is usually increased. Transverse myelitis is limited distinctly 



414 DISEASES OF THE CORD PROPER. 

by an upper border of sensory and anatomically corresponding motor 
disturbance. The onset and clinical history are acute. 

Prognosis. — The prognosis is always grave, and in proportion as 
the disease tends to invade the bulb death is imminent. Intercurrent 
affections present more than their proper danger. 

Treatment is practically futile, but should none the less be consci- 
entiously instituted. Any trace of syphilis should be heroically treated. 
The continuous use of nitrate of strychnia, as recommended by Gowers, 
in increasing dose, for long periods of time by the hypodermic method 
should be faithfully tried. Beginning with -^ grain, three times a day, 
the dose may be gradually increased, under proper supervision, to r& 
grain at a dose and even to J grain in some cases. The application of 
the thermocautery to the back, the careful use of exercises, massage, 
and electricity to the muscles, and endless attention to the general 
health and the processes of nutrition and elimination may prolong life. 
The danger of choking to death or of inducing an aspiration pneumonia 
when the pharynx is involved must be borne in mind. It is to be hoped 
that some product, perhaps of biochemistry, may be discovered that 
will maintain vitality in the degenerating motor apparatus and postpone 
the involutional changes of the disease. 

PROGRESSIVE MUSCULAR ATROPHIES NOT MARKED BY STRIKING 
HISTOLOGICAL CORD-LESIONS. 

The view-point regarding a group of clinical forms that have in 
common the feature of progressive muscular weakness and atrophy, 
often associated with hypertrophy or pseudohypertrophy of some mus- 
cles, has altered markedly during the past few years. When it was 
first found that such cases presented no spinal lesion, they were termed 
progressive muscular dystrophies by Erb, and primitive progressive myopa- 
thies by Charcot. A variety of forms were described by different 
observers, whose names, unfortunately, became associated with and 
served to fix these variations, which are now, following Erb, Brissaud, 
Sachs, and others, grouped under a common head. Writers also refer 
to the pseudohypertrophic form, the brachial, faeioscapidohumeral, pelvic, 
and peroneal types, as hypertrophy prevails or the atrophy is most 
pronounced in the various indicated regions. As material has accumu- 
lated, transition forms have been encountered with increasing fre- 
quency. Two or more of the foregoing types have been found in 
the same patient or in members of the same family. What is 
more important, the same family has presented cases of progressive 
muscular atrophy of the spinal form and also of the so-called idiopathic 
muscular variety in one or in succeeding generations. Again, there is 
an increasing number of observations going to show that in the so-called 
myopathic cases the spinal gray is not absolutely normal. A much 
larger series of observations discover changes in the muscle nelwe- 
enclings or in the peripheral extremities of the lower neurons. The 
so-called peroneal or neurotic type furnishes an intermediate form 
between the spinal and the alleged purely muscular varieties. This is 
clinically indicated by the fibrillar twitchings, the reaction of degenera- 



LESIONS AND DISEASES OF SPINAL GRAY. 41 5 

tion, the relation of the muscular dystrophy to certain spinal segments, 
and the functional relation of the affected muscles. Yet similar seg- 
mental and functional outlines are presented by all cases. This alone 
compels an acknowledgment of the spinal factor. An attentive and 
intelligent study of any given case will usually show the features of 
several of the so-called types and serve to prove their essential identity. 
The upper spinal levels or the musculature pertaining to the upper 
spinal segments are first invaded in some ; in others, the lower portion 
of the cord first manifests the disease. 

If any significance is attached to the autonomy of the lower motor 
and trophic neuron, it will be impossible to consider the cell-body in the 
spinal horn as above reproach when its axonal prolongation shows de- 
generative changes, or when its trophic control is perverted or destroyed. 
At present such change in the cell may be called dynamic or functional 
when no morphological alteration can be discovered, but the pertinent 
fact remains that actual changes appear in some instances, and the prob- 
ability is strong that improved technic will discover them in all. Dog- 
matism, here as elsewhere, is not allowable, and the very interesting re- 
ports of Leonowa x and Petren 2 on anencephalic and amyelic conditions, 
attended by full muscular development, prove at least an embryonic in- 
terdependence between muscle and nerve-cell. Sainton 3 has found well- 
marked changes in the spinal cord in the neurotic form, and Abadie and 
Denoyes, 4 in a typical pseudohypertrophic case, obtained the electrical 
reactions of degeneration that are supposed to be a part of spinal and 
nerve disintegration. Indeed, as before insisted, every gradation, from 
progressive spinal muscular atrophy to cases only showing muscular 
changes, can be adduced. Some observers, however, insist that the 
spinal changes are secondary to the muscular atrophy, 5 and well-exam- 
ined cases still fail, in some instances, to present any demonstrable cord 
variation, even when the clinical type suggests the spinal variety of 
disease. 

These muscular atrophies, to adopt that term for convenience only, 
have in common a familial tendency. They often appear in several 
members of a given family or in blood-relations of the same or different 
generations. While they may appear at any age, they show a marked 
tendency to occur in the early years of life, and commonly affect the 
roots of the extremities rather than their distal ends. They are almost 
always unmarked by changes of sensibility, by fibrillar twitch ings, and 
by the electrical reactions of degeneration. 

Etiology. — Regarding the causation of these progressive myopathic 
atrophies very little can be positively stated. Their appearance in sev- 
eral members of the same family or in several members of succeeding 
generations, their interchangeability of form, their propagation by the 
females, their appearance during the age of active growth and at de- 
velopmental epochs of life, stamp them as hereditary, familial, and em- 
bryonic. Meek has demonstrated that new-born animals possess many 
more muscle fibers than adults, as, for instance, in the biceps, and Pick 9 

1 "Nouv. Icon, de la Salpet.," June, 1899. 2 Ibid., Aug., 1900. 

3 "Neurolog. Centralbl.," 12, S. 218. 4 "Yirchow's Archiv," Bd. 151, S. 438. 

5 Pick, " Deutsch. Zeit. f. Nervenh.," Bd. xvii, 1900. 6 Pick, loc. cit. 



416 



DISEASES OF THE CORD PROPER. 



suggests that in some instances this natural disappearance of muscle 
fibers may, from prenatal or other cause, exceed physiological limits and 
produce progressive dystrophy. The flabby and wasted muscles of old 
age may be in part due to a similar cause. Age. — The great majority 
of cases appear before puberty is established, with especial frequency 
during the second dentition and at pubescence. Others are first mani- 
fest during adolescence, from eighteen to twenty-six years of age ; and 
a rapidly diminishing series is encountered later in life. It sometimes 
happens that, appearing at adult years in one generation, the myopathy 
follows in early childhood in the next. As males are rendered impo- 
tent by the disease, its transmission necessarily falls to those females 
of the family who escape and reach maturity. In addition, boys seem 



f 









Figs. 159 and 160.— Scapulohumeral type oi progressive muscular atrophy. Note the angle on right 
side of neck with lengthening of the neck, due to wasting of the trapezius, and the peculiarity of the 
deltoid. 

more frequently affected than girls. Appearing commonly during the 
years of childhood, it often follows the diseases peculiar to that period 
of life, but it is difficult to assert their causative activity. In some 
cases diphtheria has seemed to lead to it ; in others it has followed 
exposures to cold, slight injuries, and infections. Given a neuron 
feebly endowed with enduring qualities, it is not improbable that any 
condition capable of reducing the general health, or any toxic state may 
act upon it with unusual virulence. 

Morbid Anatomy. — The muscles show various morphological 
changes, depending upon the presence of hypertrophy, pseudohyper- 
trophy, or atrophy, — the final and logical end for all the affected muscles. 
The sarcode elements may be hypertrophied or atrophied. Enlarged 
fibers may be found in a mass of greatly wasted muscular tissue. There 



LESIONS AND DISEASES OF SPINAL GRAY. 



417 



is round-cell infiltration, vacuolation, splitting, division, and longitudi- 
nal striation of muscle-fibers, with hyperplasia of connective tissue and 
an increase in fat that may reach the highest degree of lipomatosis. 
The early changes consist of increase of connective tissue, possibly 
some muscular hypertrophy, then muscle atrophy and fatty infiltration. 
What appears clinically as a large muscular mass, in some instances is 
found to be a markedly lipomatous structure almost devoid of muscular 
fibers. 

Yon Babes 1 has found the muscle nerve-plates undeveloped and 
degenerated. Heubner, Striimpell, and Marinesco have described the 
peripheral nerves as degenerated in the peroneal or leg type of the 
disease ; the muscles and the anterior pyramidal cells of the cord were 
also involved. Hoppe has found similar changes in the facioscapulohu- 
meral variety. Sachs and Brooks 2 have observed universal shrinkage 
of the posterior root ganglion cells in one case. To ordinary reagents 
the nerves and pyramidal ceils usually react in a normal manner, but 
the finer technic of recent vears is likelv to determine changes in both. 





Figs. 161 and 162. — Case of facioscapulohumeral type, showing facies, tapir mouth, horizontal 

clavicles, etc. 



Symptoms. — The most striking symptoms depend upon the changes 
of contour in muscles and their loss of strength. These are variously 
combined in different cases. AVe will first take them up in systematic 
order, and finally group them in describing the common types of the 
disease. The myopathic facies depends upon the paresis of the facial 
muscles. The face presents a vacuous, sleepy, inert expression, and 
fails to adequately show forth the lively emotions that may actuate the 

1 "La Semaine Med.," Aug., 1894. 2 "Amer. Jour. Med. Sciences," July, 1901. 
27 



418 DISEASES OF THE CORD PROPER. 

patient. The brow is smooth, and the frontalis is unable to assist in 
raising the thin and drooping eyelids. The wasting of the eyelid mus- 
cles may give the eyeball a false appearance of prominence and cause a 
haggard expression. The lower lid, from the laxity of its tissues, often 
tends to droop. The cheeks and lips are flaccid, and the lower portion 
of the face droops from the bones. The eyes can not be firmly closed 
nor the lips puckered. In some cases the lips are thickened by hyper- 
trophy and drag down, increasing the nasolabial furrows. The mouth 
may then remain open constantly, with a thickened, pendent lower lip. 
In other cases the lips are thinned, motionless, and can not be retracted 
from the teeth. In either case puffing, whistling, or spitting is poorly 
performed or impossible. The movements of the eyeballs are usually 
not disturbed, but in two cases the author has noted a very great loss of 
conjugate lateral movements. Movements of the tongue may also be 
greatly limited. The palatal excursions may likewise be reduced in 
amplitude, and laryngeal disturbance may be added. 



H 






-> 



Fig. 163. — Progressive muscular atrophy at advanced stage, showing deformities about shoulders, with 
pseudohypertrophy of infra-spinati, wasting of all dorsal muscles, and spinal anterior curvature. 

Brissaud calls particular attention to an apparent lengthening of the 
neck that he finds a constant symptom, and due to the drooping of the 
shoulder. The direction of the clavicle is frequently outward and down- 
ward, instead of upward, as in health. This may be accentuated by the 
early involvement of the trapezius, causing the characteristic angle, as 
shown in figures 159 and 160. The drooping shoulder may also appear 
only on one side. Attempts to extend the arms laterally, or even to hold 
them rigidly at the sides, cause a widening of the neck by the promi- 
nence of the upper borders of the trapezii. The supraclavicular hollows 
are thereby inordinately exaggerated and the sternomastoids spring into 
great prominence. Even the upper inner angle of the scapula may be- 
come salient above the normally curved line from mastoid to acromion. 
The scapula is usually mobile, and may wing out freely from the chest. 
The spinati muscles, especially the infraspinati, have a marked ten- 
dency to pseudohypertrophy, which may add greatly to the scapular 



LESIONS AND DISEASES OF SPINAL GRAY. 



419 



deformity and accentuate the anterior curve of the lumbar spine when 
viewed from the side. This curvature is very commonly present, and 
may reach extreme proportions. It is due to the weakening of the spinal 
erectors in part, but is increased greatly when the glutei allow the pelvis 
to tip forward on the heads of the femurs, and is dragged into still 
greater prominence by the protuberant belly, due to the weakened 
abdominal muscles. 

The deltoid requires particular mention. It is commonly hvpertro- 
phied and shows the marked discrepancv between the bellies and extremi- 
ties often found in long muscles. The fibrous changes are marked at 
the origin of the muscle from the scapula and clavicle, apparently dis- 
placing the full, round shoulder-cap to the outside of the neck of the 
humerus, where it stands out as a lumpy mass (see Figs. 159 to 174a). 
Similar changes in contour are occasionally encountered in the biceps 
of the arm, in the anterior crural, and in the sural group. The forearms 
and hands are commonly spared, at least until very late in the disease, 
but K. Mendel l has reported a case showing early involvement of the 
interosseal muscles of the hands. The glutei and the gastroenemii 
are favorite locations for pseudohypertrophy. The calf-muscles also 
are frequently shortened so that the patient can not raise the toes 
from the floor while standing on his heels nor can the foot be passively 
flexed beyond a right angle. This interferes with the gait, causing 
the patients to stumble over the smallest obstacles. It may even pro- 
duce an equinovarus. In rare cases a general increase in the adipose 
tissue may greatly obscure the underlying muscular defects and maintain a 
fictitious appearance of muscular development that is belied by great 
weakness. In the same way the muscles presenting pseudohypertrophy 
look immensely strong, and feel very firm, but are 
found lacking in contractile power and subject to 
fibroid shortening. 

The attitude presented by the patients is the re- 
sult of the atrophic and paretic condition of the 
affected muscles and of the contractures that some- 
times appear in them. It, therefore, varies with 
the location of the disease. Owing to the shorten- 
ing of the calf muscles, little difficulty is found in 
maintaining the ankle-joint at a proper angle unless 
an equine position of the foot has developed, caus- 
ing the patients to stand upon their toes. Stand- 
ing then becomes extremely difficult. The position 
at the knee and hip is often entirely dependent 
upon the ligamentous support of these joints. 
This allows the pelvis to tip forward upon the 
head of the femurs and necessitates a strong 
anterior spinal bend to carry the head and 
shoulders back into the line of gravity for the 

maintenance of the equilibrium. The prominenee of the abdomen is 

thus produced and is accentuated in turn by the weakness of the abdomi- 

i "Neurol. CentialbL," July 1, 1901. 




420 DISEASES OF THE CORD PROPER. 

nal muscles. In some cases the head is tilted backward, but when the 
spinal curve is pronounced the chin may rest on the sternum. Ordi- 
narily the feet are kept wide apart to increase the base of support. 








/J* 



Figs. 165, 166, and 167.— Waddling gait in a case of pseudohypertrophic paralysis. 

The gait is broad-based and waddling (Figs. 165, 166, and 167). The 
foot to be advanced is clumsily put forward, the pelvis tilting sharply 
downward on that side, the body being inclined over the supporting 
foot as a counterpoise to the swinging limb. This is repeated in the 
opposite sense at the next step, and the patient advances in a swaying, 
waddling, awkward fashion, stumbling over the least obstacle, and falling 
heavily if the very unstable equilibrium is momentarily lost. Mounting 
stairs is often an early difficulty. 

The manner of rising from the ground is most characteristic. If 
placed on the back, the patient may have great difficulty in rising at all. 
His usual plan is to turn over on his face, then huddle himself together, 
and get upon his knees. The usually weakened psoas, vastus, and 
gluteal muscles are now inadequate to the effort of lifting him. He, 
therefore, advances the body into the " all fours " position, and, carrying 
the weight of the head and shoulders on the arms, pushes up the lower 
end of the trunk with his legs as a cow gets up by the hindquarters. 
The hands are now brought toward the feet, one is placed above the 
knee on the same side, then the other at a higher point on the thigh of 
its own side ; the shoulders and head are pushed upward, the pelvis tilts 
forward, the sway-back suddenly appears, and the patient attains the 
erect attitude by a process of climbing up his own legs (Figs. 168 to 
173) . In late stages standing and walking may be impossible. 

It is needless to say that in the cases in which the legs and pelvic 
muscles escape or are only slightly affected, the attitude, gait, and man- 
ner of rising are not disturbed. The sway-back may also disappear 
when the patient is sitting, or may then give place to a rounding of the 
back, the patient resting his elbows on his knees or otherwise gaining 
a fictitious support for the upper part of the trunk. 

The upper extremity is most affected by the impairment of the mus- 



LESIONS AND DISEASES OF SPIXAL GRAY. 



421 



cles of the shoulder-girdle. Xext in frequency the brachial group is 
affected, while the muscles of the forearm and hand are usually spared. 
In the lower extremity wasting rarely avoids the gluteal and psoas groups 




Figs. 168, 169, and 170. — Method of rising from the ground in cases of myopathy. 




Figs. 171. 172. and 173. — Method of rising from the ground in myopathy. 



and commonly affects the anterior crural distribution. The calf-mus- 
cles with the glutei furnish favorite locations for pseudohypertrophy, 
while the calf-muscles in addition are the commonest of all locations 
for fibroid contractures, which may, however, appear in any muscle in 



422 



DISEASES OF THE CORD PROPER. 



the late stages of atrophic shrinking. The small muscles of the foot 
may escape. The peronei are selected first in the leg type. 

The tendon-reflexes are usually diminished, and when wasting or 
pseudohypertrophy is apparent they are commonly abolished. The or- 
dinary case shows only a quantitative reduction of electrical muscular 
stimul at ability for both currents. In rare instances, and usually in the 
peroneal or so-called neurotic type, the reaction of degeneration may be 
obtained. Fibrillary ticitchings and severe pains are equally rare, but 
are found under similar circumstances. The sphincters are not affected. 
Sensation is intact in all its modes and tenses. A large proportion of 
these cases, and perhaps all of them dating from early childhood, show 






Fig. 174. — Showing attitude, facies, deltoid, 
and calf deformities in a case of pseudohyper- 
trophic paralysis. 



Fig. 174 a. — Advanced case of progressive my- 
opathy, at one time marked hy pseudohypertro- 
phies." Observe facies, deltoid conformation, and 
comparative integrity of hand and forearm. 



some mental backwardness and apathy. Trophic disturbances are not 
encountered, but growth may be retarded and the bones may be diminu- 
tive. 1 

Course. — These conditions are progressive. The muscular wasting 
usually steadily advances, with its attendant and increasing weakness. 
Some cases present stationary periods without assignable cause, and re- 
sume their course without adequate explanation. As a rule, the 
younger the age at which the disease appears, the more rapidly does it 
incapacitate the individual. It commonly occurs in girls at a later 
period than in boys, and then runs a slower course. AVhen commenc- 
ing in childhood, sometimes an age of forty years may be reached, but 
death usually occurs between twenty and thirty. The disease is not, as 
1 Schultze, "Deutsck. Zeit. f. Nervenh.," April, 1899. 



LESIONS AND DISEASES OF SPINAL GRAY. 



423 



a rule, fatal in itself, except by pneumogastric accidents ; death ordi- 
narily occurs from intercurrent disease. 

Varieties. — A number of clinical varieties have been described 
and are worthy of some attention, but it should be borne in mind that 
they are not distinct morbid conditions. 

The earliest recognized form is the one called pseudohypertrophic 
paralysis. It usually appears in early childhood, affects boys much 
more frequently than girls, and is marked by extreme enlargement 
of the calves and buttocks. These stand out in intensified relief next 
the wasted thighs and forward-tilted pelvis. The psoas group is early 
affected, rendering going up-stairs difficult at an early date. False 
hypertrophy is also commonly found on the dorsum of the scapula, in 
the lower border of the pectoralis, 
and the lower part of the deltoids. 
The serratus magnus, erector spinse, 
and humeral muscles commonly suf- 
fer early. The myopathic facies is 
not well marked, but can be detected 
in late cases. The forearms, hands, 
and feet are commonly spared until 
the last. The enlarged muscles 
finally shrink, and present all the 
features of those that shrink from 
the first. 

The peroneal or leg variety, some- 
times called the Charcot- Marie type, 
or the neurotic form, is marked by 
the early atrophic shrinking of the 
peroneal muscles. The calves are 
next involved and the thighs follow. 
The disease may thus be confined 
to the lower extremities for years. 
Eventually it invades- the trunk and 
upper extremities, first affecting the 
hands. It shows fibrillar twitch- 
ings, the electrical changes of de- 
generation, and presents undoubted 
cord-lesions. 

The juvenile type of Erb, also called 
the brachial form, affects mainly the 
muscles of the arms and shoulders, 
and appears in early youth, and usually in several members of the same 
family. 

The facioscapulohumeral form, or the type of Landouzy-Dejerine, 
affects, face, shoulder, and arm, or may be considered as the brachial 
form plus facial involvement. These cases furnish marked instances 
of the myopathic facies. 

The infantile or Werdnig-Hoffman type occurs in family groups, usually 
appearing during the first years of life and coming to a fatal termination 




Fig. 175.— A mixed case showing fa- 
cioscapulohumeral involvement, peroneal 
wasting, and a foot deformity similar to 
that of Friedreich's disease. There were 
fibrillary twitchings and the reaction of 
degeneration in the leg muscles. 



424 



DISEASES OF- THE CORD PROPER. 



in one to four years. The movements and control of the hip-joints are 
first affected, followed by feebleness of the muscles of the back and abdo- 
men, then of the neck and shoulders. Later the atrophy and paralysis 
affect the arms and forearms, so that the child is rendered quite helpless. 
The facial, buccal, and faucial parts are not implicated. Death ensues 
from respiratory feebleness and pulmonary complications. 




Figs. 176, 177, and 178. — Case of the neuritic variety of family progressive myopathy. 

Oppenheim, in 1900, described, a condition of congenital amyotonia 
(amyotonia congenita) which shows the same condition of the muscles as 
the family myopathies, but rarely presents family or hereditary traits. 
To distinguish it from Thomsen's disease, Haberman 1 proposes the 
name congenital atonic pseudoparalysis. It is congenital or may sud- 
denly appear after infections. The reflexes are lost from the first, far- 
adic sensibility is commonly greatly reduced, the distribution of muscular 
weakness spares the distal portions of the limbs, and there is little or no 
tendency for it to spread. Some cases recover, and most show some im- 
provement. Two postmortem examinations by Baudoin and Collier re- 



1 "Am. Jour. Med. Sci.," Mar., 1910. 



LESIONS AND DISEASES OF SPINAL GRAY. 425 

spectively showed l atrophy of portions of the anterior horns and nerve- 
roots ; one by Spiller showed no such changes. 

Several of these forms may be present in the same patient, as the 
leg type with the facioscapulohumeral variety, or pseudohypertrophy 
in the legs and the brachial type above. The hypertrophic variety 
regularly becomes shrunken finally, and lumps of false hypertrophy, on 
the other hand, may appear in muscular groups otherwise greatly 
wasted. 

Prognosis. — The outlook is always unfavorable, but some of these 
amyotrophies appear late in life, and do not apparently shorten it. The 
menace of the disease falls upon the respiratory apparatus and heart. 
Intercurrent diseases also find an easy prey in the weakened organism. 

Treatment. — Unfortunately, all forms of medicinal treatment have 
given negative results. Carefully selected exercises, graduated to the 
capacity of the weakened muscles, promise the most good. Gowers early 
insisted upon this, and Wiener 2 has recorded a very encouraging in- 
stance in which much improvement was secured. Massage to the wast- 
ing muscles may have a beneficial effect. The application of electricity 
is usually rendered impossible by the painfulness of the currents required 
to actuate the muscles if much wasted, and it is not certain that its 
vigorous use is harmless. General measures pertaining to the health, 
comfort, and education of these unfortunates will be suggested by their 
individual requirements. Sometimes a tenotomy of the heel-tendon is 
required to keep them on their feet, but the use of sustaining corsets 
and braces usually augments the muscular feebleness by depriving the 
parts of their only natural exercise. 

ARTHRITIC MUSCULAR ATROPHY. 

All varieties of joint-disease may cause wasting of the muscles re- 
lated to the joint. This occurs in two ways : (1) The inflammation may 
involve nerve-trunks passing the joint, set up a neuritis and produce 
motor, sensory, and trophic disturbances in the distal distribution of the 
affected nerves below the diseased joint. The process is simply a neuritis. 
(2) The articular filaments may be disturbed by the arthritis. Irritation 
ascends to the spinal centers and disturbs the trophic control of those 
cells related to the muscles physiologically associated with the joint and 
located on the proximal side of the affected articulation. It is a pro- 
cess acting through the reflex arc. TTe are to consider the second 
variety only. It is placed in this connection because it is a disease 
marked by disturbance of the spinal gray matter. 

Etiology. — Any joint-lesion involving the articular filaments is com- 
petent to set up an arthritic muscular atrophy. It may thus follow 
simple, acute, or chronic arthritis, infectious arthritis, the arthritis of 
gonorrhea, of rheumatism, or of traumatism. It has no proportionate 
relation to the severity of the joint-disease, but rather appears to be 
relative to the irritant qualities of the articular mischief. 

Symptoms. — In acute joint-lesions the muscular atrophy usually 
begins within a month, sometimes within a week, and the muscles 
promptly show diminished bulk and altered contours. In chronic 

1 "Brain," 1909, p. 269. 2 "American Journal of Med. Sci.," Oct., 1896. 



426 DISEASES OF THE CORD PROPER. 

arthritis — for instance, in gout and chronic rheumatism— it may very 
gradually develop, appearing very insidiously and requiring many months 
for its complete evolution. The striking peculiarity of the atrophy is 
that it is usually, and at first always, confined to the extensors of the 
joint, and involves them in their entire length. The only exception is 
in arthritis of the ankle-joint, in which case the calf-muscles waste. 
Arthritis of the shoulder affects the deltoid, of the elbow the triceps, of 
the wrist the extensors, of the fingers the interossei, of the hip the glutei, 
of the knee the anterior crural muscles, of the ankle the calf-muscles, 
of the toes the interossei of the foot. When the flexors are also involved, 
they suffer to a less degree. Sensory disturbances are absent, or are 
such as are referable to the arthritis. In occasional instances the joint- 
inflammation also affects the nerve-trunks in its neighborhood, and a 
neuritis is added, with symptoms below the joints. The wasting in- 
volves the affected muscles uniformly from end to end, and there is a 



^ 



Fig. 179. — Severe arthritic muscular atrophy in a case of multiple arthritis. 

corresponding loss of poiver. The electrical excitability of the muscles may 
be reduced slightly, but is generally increased relatively to the bulk 
of muscle present. The reaction of degeneration is never found. The 
tendon reflexes are exalted. In very pronounced cases a rectus-clonus or 
an ankle-clonus may be obtained. When the joint-disease subsides, the 
tendency is for the muscles to slowly recover, but in quite a proportion 
of cases they never completely regain their former vigor, and sometimes 
they remain permanently wasted. 

Morbid Anatomy. — The atrophic muscles are flaccid, pale, and 
inelastic. The fibers are simply diminished in size and there may be 
a little interstitial fibrosis. The only change in the nervous apparatus 
thus far recorded is in the nerve-terminals within the inflamed joint, 
due to their implication by the local disease. Better technic may be 
expected to discover cellular cord-changes. 

Pathology. — Paget, J. K. Mitchell, Vulpian, and Charcot early re- 
cognized the reflex mechanism of articular muscular atrophy. Valtat 
found that arthritis experimentally produced was followed by the 
limited atrophy in question, and Raymond found that this atrophy did 
not follow if the corresponding posterior nerve-roots were divided. 
Hoffa clinched the matter by irritating joints on both sides and cutting 
the nerve-roots on one side. The atrophy only occurred on the side 
retaining an unbroken reflex arc. The anatomical rule is that nerves 
supplying the extensors of a joint also innervate the joint. The 



DISEASES OF THE WHITE MATTER OF THE CORD. 427 

physiological association of arthritis and atrophy limited to the joint- 
extensors would in itself indicate the spinal element in the pathological 
mechanism. An interesting question is whether the symmetrical joint- 
changes and osteal conditions of gout and chronic rheumatism are not 
primarily due to the action of toxic substances upon the spinal cells 
governing the nutrition of bones and joints. Some cases of panarthritis 
or multiple arthritis symmetrically distributed, as well as the distortions 
of arthritis deformans and gout, strongly suggest a central disturbance 
as the principal and initial factor. 

The diagnosis of uncomplicated arthritic muscular atrophy is 
usually easy. It depends : (1) On the limitation or excess of atrophy in 
the extensors of a joint actively diseased or formerly arthritic ; (2) 
upon the quantitative electrical changes and absence of the reaction of 
degeneration, and (3) upon the increase of myotatic irritability. A 
microscopic section of the muscle would show a simple diminution of 
the muscle-fibers. When the joint-inflammation invades adjoining 
nerve-trunks, a neuritis may at the same time give symptoms below the 
affected joint. The atrophy usually remains sharply limited, in strong 
contrast to the invading tendencies of progressive forms. 

The prognosis depends upon the joint- condition. If the arthritis 
subsides, the atrophy usually disappears. This is the rule in acute 
arthritis with early recovery. In more persistent lesions the atrophy 
is of corresponding duration and less likely to disappear when the joint 
recovers. 

The treatment is primarily of the joint and secondarily ef the 
muscles, by massage, electricity, and gentle exercises. Systemic arthritic 
conditions, of course, must be combated. 



CHAPTER IV. 

LESIONS PRINCIPALLY AFFECTING THE WHITE 
MATTER OF THE CORD. 

Theee are a number of diseases of the spinal cord in which the 
lesions are principally confined to certain white tracts, and they are fre- 
quently classed among the so-called system diseases or diseases of 
systematized lesions. The conception on which such a classification was 
based has been so much modified that it seems better to drop it alto- 
gether, especially as there has always been a great divergence of opinion 
as to what should be embraced under that caption. Acute poliomye- 
litis, for example, which was one of the usually accepted types, is, as 
we have seen, the result of accidental infection by way of the vascular 
supply. Posterolateral sclerosis, or ataxic paraplegia, is also usually based 
upon anatomical vascular conditions, and presents so many variations that 
it can not be considered as systematized from any point of view. In loco- 
motor ataxia the spinal lesion is as sharply delimited as in any other, 
but it is a disputed question whether or not the cord-lesion is secondary 



428 DISEASES OF THE CORD PROPER. 

to initial root-changes. The morbid anatomy of the disease is so wide- 
spread that to class it as a systemic cord-lesion is to seriously contract 
the full view of the disease, and to ignore its neuritic and cerebral feat- 
ures. The secondary degenerations of the cord-tracts have been con- 
sidered in connection with the various cerebral and spinal lesions which 
give rise to them. Primary spastic paraplegia, or Little's disease, has 
been discussed with the Cerebral Palsies (see p. 248), as it is depend- 
ent upon a congenitally unfinished condition of the upper neurons, and 
furnishes one of the diplegias of childhood. 

Because the spinal symptoms of locomotor ataxia are the most salient 
of its many manifestations, and as its differential diagnosis is a constantly 
recurring problem in cord diseases, it is taken up at this time. In fact, 
however, it is a disease of the entire nervous system and must properly 
be so classed. The student should never lose sight of the fact that 
the cord-lesion in tabes dorsalis is only a small portion of its morbid 
anatomy. 

TABES DORSALIS: PROGRESSIVE LOCOMOTOR ATAXIA, 

Tabes dorsalis, progressive locomotor ataxia, leuJcomyelitis posterior, 
sclerosis of the posterior columns, are some of the many names applied 
to a symptom-group of vast proportions. It is a disease probably always 
preceded by a syphilitic infection, usually marked by a degenerative pro- 
cess in the sensory nerves, posterior nerve-roots, posterior columns of 
the spinal cord, and often by similar changes in the medulla and cerebrum. 
Clinically, there is commonly disturbance of cutaneous and joint sen- 
sation ; impairment of the muscular sense ; incoordination of muscular 
movements, especially in the lower extremities ; diminished or abolished 
knee reflexes and lessened pupillary reflexes to light ; visceral and 
trophic disturbances and paroxysmal attacks of pain. The disease pre- 
sents a progressive tendency toward complete helplessness. 

In the description of this protean disease the masterly lectures of 
Marie x have been found of great help, and in some measure his arrange- 
ment of the subject is followed herein. 

Etiology. — The principal factor in the etiology of tabes dorsalis is 
syphilis. It is impossible at present to say that it is an indispensable 
element in a given case, because chronic intoxication Avith ergot may 
induce tabetic features and similar degenerations. The same changes 
are found in pellagra, and it is at least supposable that other toxic 
states may lead to tabetic conditions. Since attention was first called to 
the parasyphilitic nature of locomotor ataxia by Fournier, in 1875, 
statistics on the subject have shown an increasing proportion of cases 
presenting syphilitic antecedents. In 1894 2 he states that in the ex- 
amination of 750 cases he finds the percentage of syphilitics varying 
from 87 to 93 for each hundred, taken separately. Erb reported 89 per 
cent., Dejerine, 92 to 94 per cent., Sachs over 90 per cent., Peterson, 71 
per cent. Reports of cases of tabes acquiring syphilis subsequent to the 
development of ataxia cannot be obtained. Such immunity argues prior 
infection. Based upon the Wassermann test for syphilis, the Noguchi, 

1 "Lecons sur les Maladies de la Moelle," Paris, 1892. 

2 "Les affectiones parasyphilitiques," Paris, 1894. 



DISEASES OF THE WHITE MATTER OF THE CORD. 429 

Ross-Jones, and Lange tests of the spinal fluid and its cellular contents, 
one may now state with much more positiveness than is generally 
allowed in medical matters that without syphilis there can be no tabes 
dorsalis. Since Noguchi has found the spirochete in the brain in 48 
out of 200 cases of general paresis and in the spinal cord in 1 case 
out of 12 of tabes, 1 we may even go farther and say that there is no 
progressive tabes without spirochetal activity. 

The tabetic symptoms may appear in from one to thirty-five years after 
the initial syphilitic sore, but ordinarily develop from the fifth to the 
fifteenth year. It is a noticeable and most important fact that the 
apparently mild cases of syphilis — those in which the secondary features 
are indistinct or entirely lacking — loom largely in the histories of tabetic 
patients. These are precisely the cases in which an intense medication 
is not urged or in which faithful pursuit of it by the patient can not be 
secured. It must be said, however, that cases of tabes are only too fre- 
quently encountered in which syphilis has run a severe course and in 
which persistent and intensive medication has been heroically prescribed 
and faithfully borne for two and three years, and yet tabes has subse- 
quently developed. 

It is rare for tabes to develop before the age of twenty-five years, 
just as it is rare for syphilis to be acquired before adolescence. In 
all cases appearing in childhood and youth, hereditary or acquired 
syphilis is present. The great proportion of cases appear between thirty 
and forty-five. As a rule, the alleged etiological factors of tabes, other 
than syphilis, are the very ones which contribute to the frequency of 
syphilis. Thus, the male sex is about ten times as frequently affected 
with tabes as the female. The same proportion obtains for syphilis. 
But among females subject to tabes Erb found the percentage of syplii- 
litics to be 89.5 per cent., practically the same as in males. 

The race question tells the same story. In rural communities and 
among the orthodox Jews cases of syphilis are comparatively rare, and 
tabes equally infrequent. Excessive venery has been accused of pro- 
ducing tabes. Its relation, if it has any, is by the increased exposure 
to luetic infection it entails. The action of cold, rheumatism, overexer- 
tion, alcoholism, and acute fevers has been much insisted upon in former 
years, but we know nothing definite about them. Many cases attributed 
to traumatism have been misinterpreted cases of organic indiscriminate 
or combined cord-lesions. In other instances the accident leading to the 
injury has been the result of tabes, not its cause, as in falls and fractures, 
the result of the previously unrecognized incoordination. The question, 
however, is still debatable. Prince, 2 after a critical examination of the 
cases in literature, is inclined to deny the traumatic origin of tabes. 
Schittenholm, 3 after reviewing the subject and the literature, reaches 
the conclusion that trauma as a unique cause of tabes is not proven, but 
that it may aggravate the tabetic condition. 

A neuropathic heredity appears to play a predisposing part to some 
extent. We thus not infrequently encounter epilepsy, hysteria, chorea, 
insanity, hemiplegia, and diabetes in the ascendants of tabetics, and 

1 "Munch, med. Woch.," April 8, 1913. 

2 "Jcur. Nerv. and Ment. Dis.," Feb., 1895. 3 "Munch, med. Woch.," 1903. 



430 DISEASES OF THE CORD PROPER. 

even, though most rarely, other cases of locomotor ataxia. May it not 
be that such instances indicate an inherited vulnerability on the part of 
a certain portion of the nervous apparatus to the toxic effects of luetic 
infection? It must be evident that only a very small percentage of 
syphilitics develop tabes. There is some ground for supposing that the 
spirochete may present a variable virulence which, under circumstances 
not now understood, may lead to the late lesions of tabes and paresis. 

The bearing of occupation is that related to syphilis. Artists, actors, 
journalists, and soldiers are frequently affected, physicians and surgeons 
not infrequently, clergymen most rarely. Country laborers, so greatly 
exposed to traumatism and exposure, very seldom present tabes or 
syphilis. 

In spite of the immense importance of syphilis in the causation of 
tabes dorsalis, it must be kept in mind that the nerve-lesion is not com- 
parable to the tertiary or secondary specific lesions, and is not similarly 
amenable to antiluetic remedies. It is a degeneration showing progres- 
sive sclerotic changes that are beyond repair. Following the views 
of Strumpell and Marie, we may hypothetically attribute the ascending 
degenerations in the nerves, roots, spinal cord, and brain to the action 
of a syphilitic toxin which primarily affects the cell-bodies of the fibers 
making up the afferent tracts. The progressive features of tabes may 
perhaps be correlated with the practically proved continuous activity 
of spirochetal life in these cases, and thereby the maintenance of a con- 
stant toxic factor. 

Edinger undertakes to explain the apparently selective activity of 
the toxic agent upon certain physiological nervous tracts and structures 
by an ingenious hypothesis. Those nerve-elements which are the most 
constantly employed are most affected. Thus, the sensory tracts, espe- 
cially in the lower parts of the cord, the pupillary activities, the bladder 
function, and the intestinal field are early and commonly affected. The 
hypothesis conjoins the elements of (1) fatigue locally precipitating the 
effects of (2) a general toxic state. 

The theories as to the pathogenesis of tabes are numerous and 
varied. Four principal ones may be mentioned. First, the toxemic 
theory with syphilis as the usual origin of the toxin. Second, the 
strangulation theory of Obersteiner and others who find the initial path- 
ological factor in pial thickening, whence arise the posterior root and 
cord changes. Third, Marie's recent contention that the changes start 
in a lymphangitis of the posterior columns of the cord ; and, fourth, 
the " Ersatz " theory of Edinger above indicated. Orr and Rows, 1 
while granting a hereditary or acquired weakness of the nervous appa- 
ratus, believe that the process is located in the sensory neurons of the 
posterior cord tracts, because of the anatomical absence of the neurilemma 
at the point where the sensory root fibers enter the cord. They find 
this to be the initial point for the degenerative process. 

Morbid Anatomy. — In this section it is purposed to take up the 
morbid anatomy of the nervous apparatus in tabes dorsalis. The morbid 
anatomy of the trophic lesions in the bones, joints, and soft structures 
will be described respectively with their clinical features. As the disease 

1 "Brain," Winter, 1904. 



DISEASES OF THE WHITE MATTER OF THE CORD. 



431 



is essentially marked by ascending degenerations, it is well to commence 
at the periphery. 

The spinal nerves are usually found to present a degeneration which 
is greatest at the periphery and most marked in, if not entirely confined 
to, the sensory fibers for the skin, muscles, and joints. The trophic 
centers for these fibers are in the posterior root-ganglion in part, but it 
seems probable that there are also superficial peripheral trophic cells 




Fig. 180.— Sections of the cord in an early case of tabes. 1, Lumbar region ; 2, dorsal region ; 3, cervical 

region (Marie). 

for at least a few of them. The muscle spindles which undoubtedly 
have a sensory function are constantly found degenerated. By some 
writers these nerve-changes are denominated a neuritis, but histologically 
the changes conform to a Wallerian degeneration. The spinal nerve-roots 





Fig. 181.— Section of cords in advanced tabes. 1, Dorsal region ; 2, cervical region. Sclerosis shown by 

white region (Marie). 



present a marked difference between the anterior or motor members, 
which are ordinarily normal, and the posterior sensory roots, which are 
usually, if not invariably, greatly degenerated. Only Avhen changes 
have taken place in the anterior cornual cells do we find changes in the 



432 



DISEASES OF THE CORD PROPER 




Fig. 182.— Section in lower dorsal 
cord in a case of advanced tabes show- 
ing complete sclerosis of the posterior 
columns and of Clarke's cellular columns 
(Marie). 



anterior roots, and then there is corresponding amyotrophy. This is 
usually a late and secondary or accidental feature in tabes. The posterior 
roots and their ganglia show much disease. Oppenheim, Simmerling, 

Marie, Obersteiner, 1 Juliusberger and 
Meyer, 2 describe changes in the root- 
ganglion cells, which are found reduced 
in size and number. Nuclear displace- 
ment and granular changes were de- 
monstrated by NissPs method, accord- 
ing to the last-mentioned authors. The 
fibers within the ganglia were also 
atrophic. The posterior roots are prac- 
tically always degenerated. The poste- 
rior root-ganglion occupies, therefore, a 
prominent position in the development of 
tabetic lesions, as it exercises a trophic 
control, both downward over the sensory 
fibers of the nerves and upward over the posterior root-fibers and their 
continuation within the posterior tracts of the cord. Changes in the 
visceral branches of the sympathetic 
nerves of a degenerative character 
have also been reported, and degener- 
ation of the fine fibers of the sym- 
pathetic arising from the viscera 
and entering the cord by the poste- 
rior roots has been demonstrated 
in a series of cases. 3 

To understand the distribution 
of the cord-lesions it is necessary to 
recall that the posterior root fur- 
nishes three sets of fibers, which 
enter the posterior horn by different 
routes and at different levels. The 
fibers of the first group, almost as 
soon as they reach the cord, enter 
the posterior gray to the inner side 
of the horn at its posterior third by 
a short route through the tract of 
Lissauer. Those of the second group 
pass to the inner side of the first in 
Bnrdach's column, and enter the 
middle third of the horn's inner 
border at a level considerably above 
their point of entrance to the cord. 
Some of them reach Clarke's 
column. The third group, arising 
mainly from the lower limbs, enter 
still nearer the median line and pass up nearly the entire length of the 

1 "Berlin, klin. Wochens.," Oct. 18, 1897. 2 "Neurolog. Centralbl.," Feb. 15, 1898. 
3 Roux, " Lesions of the Sympathetic System in Tabes," Paris, 1900. 




Fig. 183.— Schematic representation of the 
courses pursued by the sensory root-fibers enter- 
ing the cord from the root-ganglion (Marie). 



DISEASES OF THE WHITE MATTER OF THE COED. 433 

cord, constituting the columns of Goll, and terminate in the bulbar 
gray. The tract of Lissauer lying between the head of the posterior 
horn and the periphery of the cord among the entering posterior-root 
fibers, is made up of fine fibers arising from the posterior roots either 
as collaterals or as direct continuations of the numerous finer fibers of 
the root. These fibers of Lissauer' s tract, after ascending a short 
distance, enter the gelatinous substance of Rolando, which caps the 
posterior horn, and some of them penetrate the posterior horn itself. 
This tract also degenerates in tabes. 

Embryologically, the posterior columns of the cord, including 
Lissauer' s tracts, are an accession to the cord. They arise in the lateral 
neural plaques, which are finally represented by the posterior-root 
ganglia, and enter the cord by way of the posterior roots, pursuing 
their course upward in the manner indicated. This part of the cord 
only reaches full development at birth. It is to this posterior, exogen- 
ous, independently developed portion of the cord-structure that the 
spinal lesions of tabes are principally confined. 

These vary at different levels and at different stages of the disease. 
In long-standing cases the entire portion of the cord embraced between 
the posterior horns and the commissure may be sclerosed from the filum 
terminale to the medulla. In incipient cases the tracts of Lissauer and 
the columns of Burdach are affected at the lowest level, the columns of 
Goll above. Ordinarily, the sclerotic changes of tabes are most 
marked in the lumbar cord, where they commonly begin ; in other cases 
the cervical enlargement is most affected ; again, in others, the intra- 
cranial lesions of the medulla predominate, and when associated with 
cortical changes we have the progressive paralysis of the insane. 
Clinical varieties correspond to these various preponderating locations 
of the sclerotic process, and all intermediate varieties and combinations 
of lesions and clinical types are encountered. This sclerotic change, 
like that in the nerves, is a pure Wallerian degeneration. 

The lesions of the spinal gray in tabes, as far as now describable, 
consist of a degeneration of the fine nervous reticulum about the cells 
of Clarke's column near the inner border of the neck of the posterior 
horns. The change is an early one and most marked in the outer cells of 
the group. This reticulum is made up of the terminal brushes of fibers 
from the posterior roots. Ordinarily, the cells themselves are spared, 
but in some cases they, too, show degenerative changes, and the direct 
cerebellar tracts and Gower's ascending anterolateral tracts are then also 
sclerotic. These two cord-tracts find their trophic supply in the cells 
of Clarke's column ; hence their degeneration when these cells are 
affected. Clarke's column begins in the upper lumbar segments and 
extends to the seventh or eighth dorsal, when it becomes extremely 
attenuated and practically disappears at the second dorsal, to again 
appear above the cervical enlargement in the upper cervical cord. The 
lesion of Clarke's column is, therefore, most marked in the lower 
dorsal region. 

The posterior horn proper, according to Lissauer and others, shows only 
insignificant changes except in the caput of Rolando, where the fine fibers 
and radiating fibers from the posterior roots are customarily degenerated. 

28 



434 DISEASES OF THE CORD PROPER. 

The cord-lesions in tabes are commonly symmetrical, but not infre- 
quently in early stages one side will show more sclerosis than the other, 
often corresponding to greater symptoms in the limb or limbs of that 
side. 

In addition, it is to be noted that there is a clouding of the meninges 
overlying the sclerotic tracts in the spinal cord, to which much impor- 
tance has been given by some who see in it a meningitis forming an 
initial pathological process in tabes. This and the cord-changes can be 
frequently recognized by the eye, but in incipient cases recourse to the 
microscope is required to decipher the morbid condition. In some 
instances the meningeal condition reaches one of chronic inflammation, 
which, in turn, may cause a marginal myelitis that may even extend to 
the pyramidal tracts. 

Bearing upon the question of meningitis is the fact that the spinal 
fluid during life commonly presents a lymphocytosis, as has been abun- 
dantly proved by Widal, Sicard, Ravaux, Schoenbrun, and many others. 
From 10 to 20 cells in the cubic millimeter of freshly drawn spinal 
fluid is considered by Nonne as a weak positive finding; from 20 to 
60 positive, and above 60 strongly positive. In the great majority of 
cases, over 90 per cent., there is an increase of albumin in the form of 
globulin in the spinal fluid as determined by the tests of Noguchi and 
Ross- Jones, the Phase I of Nonne. At the same time the Wassermann 
serum reaction is positive in 70 per cent, of all cases of tabes both in 
the blood and spinal fluid. The colloidal gold test of Lange also gives 
a definite positive result in at least 80 per cent. 

The cranial nerves are all liable to degeneration, but this tendency is 
most marked in the optic and auditory nerves, which in effect are cere- 
bral lobes. Changes of a similar sort are not rarely found in both roots 
of the trifacial or in the nuclei of the motor nerves of the eyeball, and 
of the intra-ocular muscles, in the glossopharyngeal, pneumogastric, 
facial, and hypoglossal. Involvement of the iridociliary apparatus is, 
perhaps, the most common of all. 

The cerebral lesions of tabes, aside from those of the cranial-nerve 
nuclei or even embracing them, are those of paretic dementia, the de- 
scription of which is contained in the second part of this book. With 
this disease tabes has the most intimate relations. Fournier has gone 
to the point of considering them of identical nature and only varying 
in the primary location of the lesions. The syphilitic theory of paretic 
dementia rests on exactly the same sort of a foundation as does that 
of tabes dorsalis. A certain proportion of cases of tabes develop paralytic 
dementia; a large number of paretic dements present tabetic symptoms 
and tabetic cord-lesions. Both diseases commonly have identical 
bulbar and cranial-nerve symptoms and lesions. Though Jendrassik 
tends to consider the cerebral lesions of tabes as always initial, they are 
probably concomitant only, and due to the same specific cause. Their 
association in point of time and development is open to all possible 
modifications throughout all the varieties of each affection. The most 
pronounced types of both syndromes are presented as the sclerotic 
process falls first and most severely, respectively, on the caudal or 
cephalic extremity of the cerebrospinal system. 



DISEASES OF THE WHITE MATTER OF THE CORD. 435 

Symptoms. — From the extent of the morbid anatomical changes in 
tabes it must be evident that its symptomatology embraces nearly every 
bodily organ and function. The clinical features of the disease can only 
be fully presented by taking them up systematically. Afterward an 
attempt will be made to group them in describing the common clinical 
varieties of the malady. As we proceed, the relation of the various 
symptoms to the course of the disease will be indicated. Their rela- 
tive frequency will be shown in tabular form. 

Motor Disturbances. — The motor disturbances of tabes, while not 
the earliest, are among the most important, and are the ones which 
usually first seriously attract the patient's attention. They consist of: 
(1) ataxia; (2) involuntary movements, and (3) palsies. 

Tabetics deprived of their muscular sense by the posterior sclerosis 
or by the degeneration of the peripheral sensory fibers in the muscles 
and joints can not determine the exact positions of their limbs without 
the aid of vision. This is, no doubt, increased to some extent if attended 
by cutaneous dysesthesia, which is frequently present. They thus " lose 
their legs in the bed ? ' in marked cases, and have to verify the position 
of their limbs with their hands or eyes. In less pronounced cases they 
can not with closed eyes duplicate with one limb the position passively 
given the other by the examiner, or do so with uncertainty. Another 
manifestation of the perturbation of the muscular sense is an inability 
to accurately distinguish the difference in weight of similarly shaped 
objects held in the hands. The normal individual can usually deter- 
mine a difference of five per cent. This symptom can sometimes be shown 
by having the patient first write a short sentence with open, and then 

Fig. 184. — Ataxia of the upper extremities shown in the handwriting. 1, Written with eyes open; 

2, with closed eyes. 

repeat it with closed, eyes. The uncertainty of position and the conse- 
quent incoordination is then sometimes graphically demonstrated, while 
grosser movements with the upper extremities may be tolerably exact. 
Many patients fail to touch the nose or ear or any given point with the 
index-finger when the eyes are closed. 

Tabetics commonly present the sign of Romberg early if the lower 
portion of the cord is involved. With closed eyes they sway or may fall 
heavily if the feet are placed close together, and may even be unable to 
stand with a broad base of support. Walking backward with closed 
eyes will almost invariably determine incoordination in the lower ex- 
tremities if present in the slightest degree. So will attempts to stand 
on one foot. In advanced cases this loss of muscular sense causes so 
marked an ataxia that walking is impossible, even with the eyes open. 

To this source we must also attribute the ataxic gait that is so char- 
acteristic when well developed. It by no means appears clearly in all 



436 



DISEASES OF THE CORD PROPER. 



cases, but may usually be induced to some degree by having the patient 
walk with closed eyes, or may be manifest in the difficulty of executing 
a prompt ' 'about face," in suddenly rising from a chair and attempting 
to immediately walk forward, in descending a stair, in halting suddenly 
when advancing, and in marking time after the military fashion. In 
crossing one knee over the other the moving limb is often raised too 
high and too vigorously dropped across its fellow. When the gait is 
plainly ataxic, the patient rises from the chair with some suddenness, as 
if lifted by a spring, then balances a moment before putting himself in 
motion. The first steps are usually taken briskly and the patient may 
even plunge forward. The legs are thrown out widely. The foot goes 
forward irregularly with some rigidity, the toe up, often departing later- 
ally from the direct line, and is brought down with a shock upon the 
heel, or flat-footed. As the body is advanced, there is a tendency to 
overextension of the supporting knee-joint, which often produces a 
backward bowing of the limb and may constitute a marked deformity. 




I 




Fig. 185.— Gait in tabes. Observe over- 
extension of supporting knee, rigidity of ad- 
vancing leg, elevated toe, heavily descending 
heel, watchfulness of steps, and assistance by- 
cane. 



Fig. 186. — Showing the tendency to over- 
extension of the knee-joints in tabes, to secure 
firmness in standing. 



The foot is usually raised too high at the end of the step, but is also 
prone to catch upon any trifling obstacle as it swings forward. The 
opposite foot is then advanced in a similar irregular way, and the patient 
almost invariably aids himself by carefully watching his feet and by the 
additional assistance of one or two canes (Fig. 185). In some cases 
there is considerable uniformity in the manner of taking each step, but 
as often no two paces are exactly alike, and the patient, instead of 
advancing in a straight line, swerves more or less to one and the other 
side, often bumping into neighboring objects. 



DISEASES OF THE WHITE MATTER OF THE CORD. 437 

When he sits down he does so with suddenness, as if both knees 
gave way too soon, as they often do. In the same way he can not grad- 
ually lower himself from the erect position to a squatting attitude, but 
drops suddenly when the knees are partially bent. The sudden giving 
way of a knee sometimes causes him to fall, and, as a rule, his attitude 
and gait denote every effort to trust these joints as little as possible and 
to fix them by overextension. 

When the upper extremities are markedly ataxic, it is shown in the 
manner of grasping a small article, toward which the hand goes with 
wide-spread fingers, and grabs down on it as if it might escape by flight. 
Finally, walking becomes impossible, and the upper extremities may be- 
come useless except for wide and inexact movements. Commonly inco- 
ordination is most marked in the lower extremities, but in the cervical 
type of tabes the condition may be more pronounced in the arms. In 
all these motor affections, however, muscular power is not necessarily 
impaired. It is only the muscular sense that fails. The ataxia is 
commonly of insidious development, but in some instances comes on 
abruptly, usually as the result of some physical strain or exhausting 
condition or after a period of disuse of the limbs, as, for instance, after 
an illness or fracture. In cases where it is slowly increasing it may 
show sudden intensification, some of which may recede, but rarely does 
such sudden increase of ataxia fully pass away. 

Involuntary movements in tabes dorsalis are not uncommon, and are 
probably more frequent than reports indicate, as they are obscured by the 
major features due to incoordination. In the early as in the late stages 
they may be observed in some cases, and usually are uniform for the 
given patient. They may consist of a sudden involuntary movement of 
the thumb or a finger, or the turning of the wrist, or the jerking of the 
arm or foot. In a case now under observation the entire lower extrem- 
ity is frequently violently jerked, mainly by the flexors of the hip, and 
these movements may be repeated rapidly, but irregularly, for several 
minutes, and even for an hour or two daily, irrespective of fatigue or 
position. Such jerkings of the legs are prone to occur during sleep. 
In exceptional cases and in their terminal stages both lower extremities 
may be forcibly drawn up to the body. This occurs upon coughing, 
sneezing, or sometimes upon voluntary efforts of any sort or even upon 
the manipulation of the extremities. The slighter movements have 
been called athetoid by some, but they present nothing in common with 
the true athetotic, vermicular movements so common in the cerebral 
palsies of children. 

Fraenkel has recently emphasized the fact that myoidism is easily pro- 
voked, in the muscles which show diminished reflexes, by sharply pinch- 
ing them, or by a smart light blow with a ruler, at right angles to their 
length. 

Palsies. — The paralytic features in tabes are of two orders, and are to 
be clearly distinguished from the loss of coordinate power which consti- 
tutes the major motor difficulty. (1) One is due to the wasting of the 
muscles, a result of the involvement of the anterior horns of the cord, 
usually appearing late in the disease ; (2) the second group, to which 
attention is here confined, is the result of organic or vascular changes 



438 DISEASES OF THE CORD PROPER. 

in the cerebrum or cord. They appear in about one-fifth of the cases, 
and embrace hemiplegia, facial paralysis, lingual paresis, monoplegias, 
laryngeal palsy, and paraplegias, the last being due to focal disturbance 
in the cord. In addition, paralytic drooping of the lid constituting 
ptosis, one of the early manifestations of tabes, may be mentioned, but 
will be more fully described under disturbances of the ocular apparatus. 
The facial palsy also may be neuritic. 

A peculiarity of these palsies, as pointed out by Fournier, who has 
tabulated them, is their usual benign and fleeting character. They may 
last some days or a few weeks, when they may completely and 
spontaneously disappear, but a minority of the palsies remain per- 
manently. Some of these transitory cases undoubtedly are to be 
referred to hysteria, which not infrequently is a complication of tabes. 
The permanent cases are probably due to vascular or inflammatory 
accidents in the brain or cord ; in other instances a neuritis may 
determine a localized loss of power. 

Sensory Disturbances. — The sensory disturbances in locomotor 
ataxia are among the very earliest to appear, and persist in some form 
or other throughout the course of the disease. They are rarely the 
same in any two patients, and may vary almost infinitely in a given 
case. 

Subjective Sensory Disturbances. — The first group of sensory disturb- 
ances are those of a subjective nature, regarding which we have to de- 
pend entirely upon the descriptions of the patient. They may be subdi- 
vided into those which are intermittent and those which are permanent. 
First and most important of the intermittent variety are the so-called 
lightning pains, which are experienced in the face, extremities, or trunk, 
but most commonly in the legs. They are described in the most vigor- 
ous language and the most striking terms by these unfortunate sufferers, 
are clearly atrocious in character, and are not associated usually with 
any evidence of disturbance in the part where they locate, but excep- 
tionally after severe pains ecchymosis or some edema may be found. 

Pains of a similar character, but somewhat less in intensity, and 
transitory like the lightning pains, are lancinating, boring, burning, 
twisting sensations of a painful character. In each patient an attack of 
such pain is likely to be followed by a similar attack in a similar location, 
and these attacks or crises occur in some cases with a degree of regu- 
larity every week, month, or year. Ordinarily, they are attributed to 
rheumatism, and it is not uncommon for patients to be treated for 
rheumatic disturbance for months and even years before the tabetic 
nature of the painful affection is recognized. A careful examination 
in a case marked by repeated painful attacks will almost invariably 
determine other evidences of tabes. The diagnosis should be made. 
When commencing early in the disease, the pains may disappear after 
the ataxia has become prominent, but if they do not appear in the early 
stage they are not likely to appear later. In some cases they persist 
through the entire duration of the disease. Cases presenting very 
severe pains early seem to run a more tardy course than those in which 
pain symptoms are insignificant. 

Another variety of subjective pains are associated with the viscera, 



DISEASES OF THE WHITE MATTER OF THE CORD. 



439 



and constitute anal, testicular, ovarian, urethral, vesical, gastric, laryngeal, 
and intestinal crises, which will be taken up in the consideration of the 
visceral disturbances of the disease. 

Tabetics also frequently complain of attacks of muscular cramps, 
which, like the lightning pains, have a tendency to come on in gusts, 
and frequently compel the patient to take to his bed. Their common 
location is in the muscular masses of the lower extremities or in the 
small of the back. 

The second class of pains is more permanent in character, lasting 
weeks, months, or even years, perhaps appearing and disappearing sev- 
eral times during the course of the disease. One of the most important 
of these is the girdle sensation. The patient describes it as the feeling 
of a tight belt, and may frequently attempt to relieve it by loosening 
his clothing. It may be situated in the lower portion of the abdomen, 
or at the level of the umbilicus, or about the chest. It is usually rather 
narrow in its vertical extent, but may be of considerable width, giving 
rise to sensations of an iron or rigid corset. An analogous sensation is 
sometimes felt in the extremities as of a bracelet, or as if the legs or arms 
were wound with rope. Paresthetic sensations of a more or less per- 
sistent character are described by the patient as the creeping of ants or 
insects, a feeling of fullness in certain parts of the body, especially along 
the ulnar border of the forearm and hand, and in the lower extremities 
below the knees. In other cases the sensation is that of a cobweb or 
some light fabric upon the skin. 

Sensory Disturbances Partially Objective. — Analgesia is one of 
the commonest manifestations of tabes, affecting not only the cutaneous 
extent, but the muscles, bones, and joints. Even dislocations and frac- 
tures, perforating ulcers, and other diseases of the deeper parts, as well 
as of the skin, are frequently unattended by pain. Very often the 
patient is unaware of the analgesia and is surprised to observe that a 
needle can be thrust deeply into the tissues without giving rise to any 
discomfort. This loss of the sensation of pain is frequently distributed 
in plaques upon the trunk and extremities without reference to the ordi- 
nary manifestations of the disease, and does not spare the surface of the 






Fig. 187. —Tabetic cuirass of blunted tactile sensation. 



head. It has a tendency to symmetry, affecting both upper extremities, 
both lower extremities, or the trunk bilaterallv. On the head, however, 



440 DISEASES OF THE CORD PROPER. 

there is a tendency to a unilateral distribution of the analgesia. On the 
trunk the most common location for the analgesia is over both pectoral 
regions, about the umbilicus, in each inguinal region, and over the 
shoulders. Frequently these analgesic plaques are marked by a hyper- 
esthetic border. On the upper extremities the analgesia most commonly 
affects the fingers or the ulnar border of the forearm. In the lower 
extremities it is the sole of the foot, the heel, and the toes ; on the 
thighs the inner surface, corresponding to the adductors. The nerve- 
trunks, as the ulnar at the elbow and the external popliteal at the head 
of the fibula, are frequently found insensitive in very early stages of 
the disease. The testicle commonly loses its normal sensitiveness to 
pressure. 

On the trunk is frequently found what may be denominated the 
tabetic cuirass. In about four-fifths of the patients, even at an early 
stage, there appears a band about the chest, which may be most marked 
on the anterior or more commonly the posterior surface, or rarely con- 
fined to the pectoral regions. This area presents a diminished sensation 
to touch (Laehr, Patrick, Bonar). Its outline above and below is some- 
times hyperesthetic. It varies in vertical width from three or four 
inches to an area which would be covered by a corset, and is sometimes 
associated with a girdling sensation. This cuirass distribution is not 
ordinarily one of analgesia, but of tactile loss, though it may be both. 
Its limits are those of the cutaneous extent of the spinal segments, and 
do not conform to the course of the intercostal nerves. These areas of 
tactile anesthesia have four principal localizations : (1) In horizontal 
patches or girdles on the trunk ; (2) the internal surface of arms and 
forearms and ulnar borders of hands ; (3) the perineal and genital 
regions ; (4) the outer margins of the feet, outer sides of legs, and the 
antero-internal surfaces of the thighs. They are often related 1 to the 
painful disturbances of neighboring viscera. 

The sensibility of the bones is reduced. This is shown by the re- 
duction or loss of perception of the vibrations of an active tuning-fork 
held in contact with subcutaneous bony parts. Bier recounts painless 
joint operations done without anesthetics. Probably all the deeper 
parts share in the analgesia. 

Hyperalgesia is a common condition in tabes. It may appear in 
plaques similar to those of analgesia, but has less tendency to symmetry 
of distribution and is less persistent. These hyperalgesic plaques fre- 
quently are the foci of lightning pains and often appear during the 
painful crises. Hyperalgesia may be found not alone for the painful 
stimulus of the needle, but for cold and other sources of pain. Many 
patients in the early years of the disease find hot water intolerable in 
the bath and frictions by hand or towel almost unbearable. 

In some instances the stereognostic sense is materially impaired and in 
a ratio disproportionate to other sensory modifications. 2 Thus, in the 
hands, which may be the seat of only slight paresthesia, a match-box 
may not be told from a coin and other familiar objects similarly mis- 
taken or unrecognized. 

Modifications of the cutaneous sensations are quite frequent. Com- 
1 Marinesco, "Sem. Med.," Oct, 13, 1897. 2 Rennie, "Br. Med. Jour.," Feb. 7, 1903. 



DISEASES OF THE WHITE MATTER OF THE CORD. 441 

monly the transmission of sensation from the extremities is retarded so 
that the patient, when instructed to do so, does not indicate the percep- 
tion of the pin-prick upon his shin or foot within a period of three, 
five, or even ten seconds, or more. In a general way the retardation 
of the transmission of sensation increases with the distance of the part 
from the head, not only because of the distance, but from the fact that the 
extremities usually present the greater disturbance of sensation, probably 
owing to the changes in the distal ramifications of the sensory nerves. 
A peculiarity is that the retardation of sensation may be dissociated. 
Painful sensation may be retarded, while that for touch is not, so that 
the patient feels the prick of a pin immediately as a touch and subse- 
quently as a pain. Frequently patients are unable to distinguisn the 
character of the stimulating impression, recognizing a prick as a pinch. 
This, in other words, is an expression of the diminution of their sensi- 
tiveness. Tabetics may fail to properly locate the stimulus, — a pinch 
on the foot may be referred to the knee or to the opposite foot. In 
general, the tactile sensations are abolished later and to a less degree 
than sensations of pain, but they are also frequently modified, and this 
gives rise to additional difficulty in locomotion. The patients express 
themselves as having a feeling of walking upon a thick carpet, upon 
cushions, upon rubber, or other yielding substances. 

It may be found that a stimulus not at first recognized is appre- 
hended upon being repeated a few times with some rapidity, the summa- 
tion of effects being competent to reach a sensorium cut off from a 
single impulse. Again, a stimulus at first competent may, upon repe- 
tition, fail to rouse the sensorium by exhaustion apparently of the 
conduction apparatus which, after a short interval of rest, again responds 
to the original excitation. Even the syringomyelic dissociation of 
cutaneous sensibility has been encountered in tabes, but commonly it is 
devoid of those exact and equal boundaries for all forms of sense 
anomalies which are found in the true syringomyelic syndrome. 1 

In all cases it is necessary to use the utmost caution in making tests 
of sensation, as already indicated in Part I. Some allowance also must 
be made for the intelligence and temperament of the given patient. 

Disturbance of the Reflexes. — The knee-jerks are lessened, un- 
equal, or more frequently abolished, and that at an early stage of tabes, 
in at least nineteen out of twenty cases. The lost knee-reflex, often 
called WestphaFs sign, must be sought with great care, but in no 
instance should the patellar reflex be considered extinct unless the plan 
of reinforcement and all precautions are taken to elicit it. It may also 
be well to recall that it is diminished in advanced age, in sleep, by 
fatigue, in exhausting illness, and by any condition, such as a peripheral 
neuritis, that destroys the afferent and efferent paths or the spinal 
center. It is also possible that very rarely a healthy adult may be 
found without a knee-jerk. The Achilles reflex ordinarily fails with the 
knee-jerk. In fact, it may disappear before the knee-jerk is lost and 
constitutes a valuable early test. The reflexes in the upper extremity 
fail when the cervical cord is involved, and Fraenkel claims that the 
triceps reaction is lost as commonly and as early as the knee-jerk; 2 but 
1 Raymond, "Legons," Paris, 1901. 2 "Deutsch. Zeit. f. Nervenh./'July, 1900. 



442 



DISEASES OF THE CORD PROPER. 



this is clearly erroneous. The superficial reflexes, such as the plantar, 
abdominal, dorsal, and scapular, are variable. The iris reflex to light is 







Fig. 188. — Abnormal range of flexion of hip-joint due to hypotonias in tabes. 








Fig. 189.— Abnormal abduction of thighs, the " split" position, due to hypotonus in tabes. 




Fig. 190. — Abnormal flexibility of spine and hips in tabes due to hypotonus. 

usually abolished early, but will be considered later with the disturb- 
ances of certain other organic reflexes, including those of the cremasters. 
All muscles in the involved areas present a peculiar lack of tonicity, 
of which the reduced or lost tendon reflexes are a manifestation. This 



DISEASES OF THE WHITE MATTER OF THE CORD. 



443 



hypotone is readily demonstrated by the ease with which over-extension 
can be imparted to knees, ankles, and elbows, and in the great range 
of flexion at the hip and of abduction of the thighs. 

Disturbance of the Visual Apparatus. — Both the external and 
internal portions of the ocular mechanism are frequently impaired in 
tabes. 

Ptosis and squints, usually unilateral, sometimes bilateral, are of com- 
mon occurrence in the preataxic as well as in the later stages of loco- 
motor ataxia. They may be and often are temporary and fleeting, almost 
momentary, but show a marked tendency to recur and occasionally are 
permanent. Careful questioning will commonly recall to a tabetic's 
mind some such ocular experience. Its temporary character is the best 
evidence of its tabetic, we may even say of its syphilitic, nature. Any 
of the extrinsic muscles of the eye may be selected by the disease, but 
those under the control of the third cranial nerve show more than their 
due proportion of paralytic disturbances. They may be gradually in- 
vaded, and a progressive external ophthalmoplegia results with perma- 
nent disability. Lacrimation, exophthalmos, enophthalmos, nystagmus, 
and reduced ocular tension on one or both sides has been noticed in rare 
instances. 

The pupils are affected in the great majority of tabetic cases, and 
furnish some of the earliest and most important diagnostic symptoms. 
Every possible pupillary modification may be encountered in tabes, — 
inequality, irregularity, miosis, mydriasis, sluggishness, loss of light reflex, 
loss of accommodation reflex, loss of reflex to pain, and absolute iridoplegia. 
There is only one other disease that has a parallel in this matter of 




Fig. 191.— Contracted irregular visual fields in tabetic optic atrophy. 1, Left eye; unbroken line 

bounds form field, broken line bounds field for red in which there is a blind scotoma ; small central 

field is for green ; 2, right eye ; unbroken line bounds form field ; small inner field is for green. 

pupillary disturbance, and that is paretic dementia. The analogy, if 
not identity, of these diseases has been sufficiently indicated. These 
various pupillary disorders may be combined in any and every way. 
Sluggishness of the pupils to light and slight inequalities and irregular- 
ities of outline are usually encountered very early in the disease. Later, 



444 DISEASES OF THE CORD PROPER. 

contracted pupils still responding to accommodative efforts but not to 
light, constituting the Robertson pupillary sign, are noted, and still later 
loss of reflex to pain, and eventually complete iridoplegia, with or with- 
out paralysis of accommodation, is often found. Dilated pupils may be 
subsequently contracted, but pupils once contracted to an extreme degree 
very rarely again dilate widely. The fixed pupils of tabes resist agents 
that ordinarily control the pupillary muscles, and if forced from their 
abnormal proportions, as by belladonna, return to them only after sev- 
eral weeks, and sometimes not at all. The dissociation of the light and 
accommodative reflex is, perhaps, the most important of all ocular 
symptoms, and appears early in over one-half of all cases. Over sev- 
enty per cent, of tabetics show some pupillary disturbance. 

The optic nerve degenerates in about ten per cent, of tabetics, and 
this occurs in those patients who have shown ocular palsies more fre- 
quently than in others. The optic atrophy is usually bilateral, but has 
a tendency to attack the left eye first. Its natural termination is in 
blindness. In rare instances it comes to a standstill, or even recedes a 
trifle. It may cause blindness in a few months, or many years may be 
required for the extinction of sight. As a matter of fact, the optic 
atrophy may have advanced to a considerable development before the 
patient notices any visual impairment. The order of symptoms is usu- 
ally : (1) A contraction of the color-fields, green, red, and blue fading 
in the order named ; (2) the form-field shrinks, and (3) vision begins to 
diminish. The retraction of the field is usually most pronounced on the 
temporal side, but may be irregularly concentric. In occasional instances 
hemianopsia or quadrant defects have been observed, and even central 
scotomata. These partial fields are, perhaps, properly attributed to a 
retrobulbar neuritis. The characteristic ophthalmoscopic picture from 
the first shows a blanching of the papilla, which becomes grayish or 
bluish- white and pearly. Its border is sharply defined, and sometimes 
it is stippled by the cribriform markings. Eventually the vessels diminish 
in size, first the arteries, then the veins. 

Optic atrophy may be a very early tabetic feature, and usually ap- 
pears either before or during the early portion of the ataxic stage, while 
the patient is still walking fairly well. It is a clinical fact of much value 
that, as a rule, the cases developing optic atrophy early do not show 
much ataxia, and the locomotor difficulties are only those of blindness. 
When appearing in the ataxic stage there is little or no further increase 
of incoordination, and in certain cases the ataxia almost or quite disap- 
pears. Benedikt says it invariably subsides. 

Auditory Symptoms. — Morpurgo 1 has shown that eighty per cent, 
of tabetics present auditory defects which may appear early or late in 
the disease. 

The auditory nerve is subject to a degeneration similar to that noted 
in the optic and about as frequently. In other instances the disturbance 
is in the middle or external ear. The impairment of hearing is frequently 
insidious and extremely slow in reaching a complete degree, but in some 
cases comes on with rapidity or even abruptly. It is usually bilateral 
but commonly more marked on one side than upon the other. The dis- 
1 "Archiv. f. Ohrenheilk.," 1890. 



DISEASES OF THE WHITE MATTER OF THE CORD. 445 

tinction between disease of the nerve and disease of the conduction appa- 
ratus is determined by Rhine's test (see page 65). Weber's test, which 
consists of placing the handle of a vibrating tuning-fork on the vertex, 
enables the patient to thus hear the note better in cases of middle or 
external ear disease than when the nerve is affected. The disease of 
the middle ear is, perhaps, sometimes of a dystrophic sort. 

Many tabetics are troubled with tinnitus and vague subjective audi- 
tory sounds. Others have constant or paroxysmal attacks of aural 
vertigo that may be sufficiently severe to provoke vomiting and great 
prostration. Auditory hyper excitability to electric currents was found by 
Marina 1 in eight out of eleven cases of tabes, which also indicates the 
frequency of disturbance of the auditory apparatus in locomotor ataxia. 
Bouuuier 2 attributes to labyrinthine disturbance many of the common 
signs and symptoms of the disease. He enumerates deafness, vertigo, 
ataxia, nystagmus, diverse disturbances of oculomotricity, pupillary 
changes, and a large number of others, and found labyrinthine irregu- 
larity in 80 per cent, of cases examined. 

The senses of smell and of taste have also been found impaired in rare 
cases, even to the point of complete loss. A careful examination for 
similar defects in all cases would probably show them to be somewhat 
common. Klippel and Julian 3 have reported nasal crises marked by 
curious sensations in the nose and nasopharynx and violent bouts of 
sneezing. 

Visceral Disorders. — The visceral features of tabes are among the 
most interesting and constant manifestations of the disease, and amoug 
those most frequently overlooked and misinterpreted by the physician. 
They consist, for the most part, of paroxysmal attacks attended by pain 
and disturbed function of some viscus, as the stomach, intestine, or 
bladder, and are called tabetic crises. Other visceral disorders are of a 
continuous character, and are attributable to impairment of the nervous 
and vasomotor control of the parts. Though any viscus may be affected 
in tabes, the crisis features for the given patient are usually limited and 
uniform in their manifestations. 

The Stomach. — Gastric crises in tabes are very common. They 
are characterized essentially by pains and vomiting. The pains are 
located in the pit of the stomach and often radiate in various directions. 
They are occasionally referred to the heart ; indeed, angina pectoris 
may appear with them. They are intense, and sometimes so severe as 
to seem unbearable, and may actually cause insensibility. Sometimes 
they strike through to the back or flash into the flanks and through the 
abdomen. The vomiting is repeated and intractable. Sometimes it is 
attended with excessive straining, and again the gastric contents are 
ejected with very slight eructative efforts. The vomitus at first consists 
of undigested food and then of gastric mucus in large amounts, and 
finally of bilious mucus in the protracted attacks. The vomiting is fre- 
quently repeated, only a small amount being ejected at a time after the 
first efforts. The slightest ingestion of food or liquid of any sort 
promptly provokes a repetition of the emesis. Sahli, Hoffmann, and 

1 " Archiv. f. Psych.," t. xxi, p. 156, 2 "Nouv. Icon, de la Salpet.," 1899. 
3 "Kev. de Med.," Jul. 10, 190C. 



446 DISEASES OF THE CORD PROPER. 

others have shown that there is hyperacidity due to an increase of 
hydrochloric and lactic acids, most marked at the beginning of the 
attack and gradually diminishing as it proceeds. 

The gastric crisis is usually attended by a state of marked prostra- 
tion that may even recall the collapse of the algid stage of cholera and 
is usually equal to that of severe seasickness. The patient, cold, 
blanched, and covered with profuse perspiration, presents the appear- 
ance of severe shock. 

Gastric crises, like all the critical manifestations of tabes, are of 
sudden onset and abrupt termination. They may last an hour or two, or 
several days or weeks without intermission. In spite of the great 
thirst that attends prolonged attacks, the smallest amount of liquid is 
not tolerated by the stomach, and alimentation per os is out of the 
question. Suddenly the patient may feel hungry, the pains may 
abruptly cease, and both food and drink may be taken freely without 
further disturbance. 

Gastric attacks often occur in the preataxic stage of posterior 
sclerosis and are attributed to all sorts of indigestion, but it is difficult 
to identify any actually determining cause. They sometimes occur but 
once in a given case. Ordinarily, they are repeated, and sometimes with 
regularity, every few weeks or months, or even daily. After several 
years they may diminish in frequency and definitely cease, or they 
may persist throughout the entire course of the disease. They may 
even cause a fatal termination. 

Variations are not uncommonly encountered in which the gastric 
crisis may be unattended by much pain or the pain may be excessive, 
and vomiting slight or absent. They may closely simulate hepatic or 
nephritic colic, or be marked most by the generation of an extreme 
flatulency. Occasionally there is considerable blood in the vomitus, 
giving rise to the suspicion of gastric ulcer. 

The intestine is often disturbed in tabes. In some cases there is 
persistent causeless diarrhea, marked by frequent slight liquid stools, not 
attended by colics or pain. In other instances constipation is beyond 
control and fecal accumulations, apparently even above the colon, cause 
distressing and persistent complaint. Intestinal or rectal tenesmus occa- 
sionally drives the patient almost distracted. There is a constant desire 
to defecate, but efforts are abortive, or only result in a small passage. 
The repeated imperative character of these attacks, with their apparent 
causelessness, should serve to distinguish them. A rectal examination 
is usually negative. Rectal crises may simulate dysentery, particularly 
as considerable blood may appear in the stools. In many late cases the 
anal sphincter is incompetent to retain fluid bowel-contents or injections. 

The urinary apparatus presents some of the earliest indications 
of tabes. Among the first symptoms is a difficulty in starting the urinary 
discharge and in completely evacuating the bladder. This condition 
must be intelligently investigated, as it may escape the patient's atten- 
tion or be deemed of no significance. As a rule, tabetics have to make 
forceful abdominal expulsive efforts to complete micturition, and in some 
cases this is aided by pressing the hands deeply into the lower belly- 
wall. Not infrequently after protracted waiting, the feeble stream sud- 



DISEASES OF THE WHITE MATTER OF THE CORD. 447 

denly ceases to flow, or after the act is thought to be completed a small 
amount of urine wets the clothing. Complete retention is rarely en- 
countered, but daily catheterization may be required in some cases. 
Similarly, partial or complete incontinence is met with, but what is more 
common is an inability to control the escape of a few drops or more of 
urine if the slightest desire to urinate arises, or even the thought of it 
occurs. Very frequent urination may be due to a weak sphincter or to 
cystitis, which often arises from retention. 

The character of the urine in tabes is frequently altered. Glycosuria 
is somewhat common among tabetics. The hereditary relation of tabes 
and diabetes has been already suggested. The medullary lesions of 
tabes may stand for something in this relation. In some cases there is 
a quantitative diminution of the urea, or phosphates, or chlorids. Some- 
times the quantity of urine is notably lessened, sometimes greatly in- 
creased in a paroxysmal manner. 

The mucous lining of the urethra and the bladder may be insensitive, 
but that does not prevent their being the seat of atrocious painful 
attacks that constitute vesical crises, or, extending to the lumbar regions, 
suggest the term nephritic crises. During such attacks the patient is 
constantly tormented with the desire to urinate, but fails to express 
more than a drop or two at a time. Meantime the colicky, darting, 
intense pains about the neck of the bladder and down the urethra or 
thighs may give rise to intense suffering. Lightning pains in this region 
are not infrequent and vesical and rectal crises are often associated. 

The generative functions frequently undergo modifications in 
tabes. In over one-half the cases there is a loss of sexual appetite and 
more or less impotence. Erections either completely default or are par- 
tial, and ejaculation does not take place. Impotence may develop very 
early, and sometimes is the first symptom to attract the patientV notice. 
In a majority of these cases there is an early genital excitement that has 
sometimes led to sexual excesses and has perhaps contributed to the 
idea of the causal role of such practices. The same thing is seen in 
general paresis. Other reflexes than the genital may be exaggerated in 
the initial period of tabes, as Avitness the increased knee-jerk that 
appears in very exceptional instances, and the spasmodic action of the 
bowels, rectum, and bladder. 

With the loss of generative aptitudes in tabes we usually find a 
diminution or complete extinction of the cremasteric reflex. As there 
is a loss of appetite these patients make no complaints, contrasting 
sharply with the sexual neurasthenic, whose cremaster also is likely 
to be extremely active. In the same tabetic condition the bulbocavernous 
reflex of Onanoff, or the virile reflex, as it is called by Hughes, is 
usually, if not always, absent. To secure this reflex the index-finger 
of the examiner is firmly placed over the bulbar portion of the urethra 
at the angle of the scrotum and perineum, and the mucous membrane of 
the corona glandis lightly pinched. The palpating finger will distin- 
guish the contractions of the bulbocavernous and ischiocavernous mus- 
cles. This reflex is said to be invariably present in healthy males, and 
even in other nervous diseases, whenever complete erection is possible. 

Testicular analgesia has been already mentioned. It is present in 



448 DISEASES OF THE CORD PROPER. 

about four-fifths of all tabetics, and is not infrequently attended by 
atrophy of the testicle. 

In female tabetics there are analogous changes in the sexual sphere. 
In both sexes the genital organs are occasionally the site of painful 
crises that are commonly misunderstood, especially as they are prone to 
occur in the preataxic stage of the disease. 

The Respiratory Apparatus. — Hyperesthesia and anesthesia of the 
soft palate and diminution or increase of pharyngeal and laryngeal sen- 
sibility may be found separately or variously combined in cases of loco- 
motor ataxia. Oppenheim has described pharyngeal crises, consisting 
of rapidly repeated, noisy, and very painful swallowing efforts that are 
involuntary. They last from a few minutes to a half-hour and are at- 
tended by some facial cyanosis and abundant perspiration. The writer 
has observed them in a case with progressive involvement of the cranial 
nuclei. A spasmodic dry, barking cough is not very uncommon. 

Laryngeal crises are tolerably common in tabes, and vary greatly in 
degree and intensity in different cases. Sometimes there is a noisy, 
croupy inspiration, to which a cough may be added that strongly sug- 
gests whooping-cough. There is more or less dyspnea, pain, anxiety, 
and depression. In some instances the dyspnea seems to be absolute 
and the patient falls suddenly, cyanotic, unconscious, and convulsed. 
After a few moments the laryngeal spasm yields and full consciousness 
immediately returns. This form of laryngeal crisis has been called the 
laryngeal stroke by Charcot. 

In patients subject to these crises they may be provoked by slight 
irritation of the laryngeal mucous membrane by mechanical or other 
means, and in some instances by pressure of a sensitive point on the 
side of the neck between the lower border of the larynx and the sterno- 
mastoid. Like other tabetic crises, they may increase in severity and 
frequency or grow less intense as time passes, and they have the same 
tendency to recur. Though giving rise to alarming symptoms, they are, 
ordinarily, without danger in themselves. They appear to be due to 
unusual sensitiveness of the laryngeal surfaces. 

Laryngeal palsies are encountered in tabes and may or may not be 
attended by laryngeal crises. The palsy may affect any of the laryn- 
geal groups of muscles on one or both sides, but seems to exercise a 
preference for the dilators. Corresponding respiratory and vocal symp- 
toms follow. The nerves, roots, and bulbar centers have been found 
variously degenerated, and the muscles themselves secondarily atrophied. 
Bronchial attacks, marked by spasmodic cough and respiratory difficulty, 
are rarely encountered. 

The Vascular Apparatus. — Taking into view the fact that syph- 
ilis is one of the commonest causes of vascular deformities and disease, 
the frequency of arterial sclerosis and cardiac abnormalities in loco- 
motor ataxia is not surprising. Aside from the cerebral vascular acci- 
dents arising from this source, angina pectoris, associated sometimes with 
gastric crises, is encountered. Valvular disease, affecting both the mitral 
apparatus, usually in the form of insufficiency, and the aortic valve, 
mainly by stenosis, is found with considerable frequency. In 300 cases 



DISEASES OF THE WHITE MATTER OF THE CORD. 449 

Limbach 1 found mitral insufficiency alone in 2 cases; with aortic stenosis 
once; 2 cases of aortic insufficiency were noted, 1 of aortic insufficiency 
and stenosis, and 1 aneurysm of the aorta, — 7 in all, and all syphilitic. 
Lesser 2 found aneurysm in 19 out of 96 cases, 20 per cent. A rapid 
pulse, from 100 to 120, is not uncommon. The blood may be normal or 
impoverished and frequently contains cholin. It is almost invariably 
Wassermann positive. 

The temperature in tabes is normal or only shows variations de- 
pendent upon intercurrent associated or secondary disorders. Pel 3 has 
reported a case with crises of high temperature and rapid pulse lasting 
about twenty-four hours. There were also coryza, lacrymation, photo- 
phobia, and lancinating pains in the face and eyes. Oppler 4 reports a 
similar case. 

Trophic Disorders. — The disturbance of nutrition in tabes finds 
some manifestation in nearly every case, and there is no tissue or struc- 
ture that may not be affected. The great majority of tabetics, and 
perhaps all in the later stages, show a depravity of the general nutrition 
that can not be explained by their physical inactivity, by pains, or by a 
syphilitic cachexia. In the preataxic and ataxic stages the general 
malnutrition is frequently well marked, but exceptionally the tabetic is 
plump, ruddy, and apparently vigorous. 

Osseous System. — On the part of the skeleton tabetic dystrophy 
presents two striking clinical manifestations, — spontaneous fractures and 
dystrophic arthropathies. 

Spontaneous fractures in tabes are more frequent than might be 
supposed, as they are not by any means always referred to their proper 
origin. It would appear that they are more common among women 
than in men. They may occur in the very early stages of posterior 
sclerosis, during the ataxic stage, or in the last phase of the disease. 
Their most frequent site is the femur, especially the shaft ; the leg bones, 
and those of the forearm ; but any long bone may present this accident, 
and even the vertebral bodies are sometimes thus affected. The fractures 
may be repeated or multiple in the same subject. Separations of 
epiphyses and of the bony insertions of muscles are also encountered. 

Tabetic fractures are marked by the practical absence of pain in the 
affected part, and by the usually insignificant force that occasions them. 
They have followed merely the crossing of the knees or have taken 
place while the patients have been calmly walking on a smooth surface. 
Union takes place readily, but, owing to the lack of pain, which ordi- 
narily reinforces the immobilization of the parts by splints, movements 
of the limb are not inhibited. Shortening and extensive callus are the 
natural results. 

The bones in tabes and paretic dementia present a certain fragility 
which lays them liable to fracture during life. To the naked eye they 
often present a porosity and a shrinking of the compact substance, with 
an increased sponginess of the more open structures and sometimes an 
enlargement of the medullary canal. Microscopically, the Haversian 
canals are dilated and some decalcification is evident. The osteoblasts 

1 "Deutsch. Zeit. f. Nervenheilk. , " 1895. 2 "Berlin, klin. Woch.," Jan. 25, 1904. 
3 "Berlin, med. Woch.," Jun. 26, 1899. 4 "Berlin, klin. Woch.," 1902. 

29 



450 



DISEASES OF THE CORD PROPER. 



are shrunken and sometimes show fatty degeneration, while the medul- 
lary substance is increased to an amount corresponding to the diminished 
osteal portion. This results in an inversion of the ordinary ratio 
between the organic and inorganic elements. Normal bones are about 
two-thirds inorganic substance ; tabetic bones are about two-thirds 
organic matter. In other words, these bones present a rarefying osteitis. 
By some this is attributed to changes in the nutrient artery and nerve, 
which have been found sclerotic and neuritic. For others the lesion is 
a manifestation of the trophic disturbance arising from modification of 
trophic cells in the spinal ganglia and cord. 




Fig. 192. — Spontaneous fractures and arthropathy disintegrations (Charcot). 

Tabetic Arthropathy. — One of the early features of tabes is an 
abnormal range of joint-motion. This may be observed even in the pre- 
ataxic stage, but is usually developed after incoordination has appeared. 
Putnam 1 was among the first to call attention to the fact that the joints 
in tabetics could be forced into extreme flexion or extension without 
producing much or any pain, and attributed the fact to analgesia. 
Frankel and Faure, 2 in a fuller study of the matter, show the extreme 
1 "Bost. M. and S. Jour.," Aug. 29, 1895. 2 "Nouv. Icon, de la Salpet.," July, 1896. 



DISEASES OF THE WHITE MATTER OF THE CORD. 451 

range of motion that is customarily found in the joints in this disease. 
They found that in locomotor ataxics the foot, wrist, elbows, and fingers 
are similarly affected. Their patients could execute at the first attempt 
the "split" attitude that acrobats only attain by years of practice. 
(See Figs. 188, 189, 190.) They attribute this abnormal flexibility to 
muscular and joint analgesia in part, but principally to a loss of the 
muscular tone. This condition of the joints places them at a certain 
disadvantage, so that the joint-surfaces are not properly coapted and 
ligamentous stretching is often induced. Taken with the incoordina- 
tion of movement, there is little doubt that the joints are subjected 
to unusual traumatic twistings and shocks. In addition, there is present 
the trophic disturbance marked by fragility of bones, and out of it all 
arises the tabetic or Charcot's joint. Its frequency in syringomyelia adds 
force to the belief that the spinal lesion is the principal cause, the trau- 
matism the excitant. 





Fig. 193.— Tabetic arthropathy of the left knee. 

A tabetic arthropathy is marked at first by (1) rapid or even sudden 
onset, (2) entire or nearly entire absence of pain and tenderness, and (3) 
enormous swelling of the adjoining parts. The patient, while walking or 
using a member, may notice a sharp cracking in a joint and find that the 
limb feels heavy and more unmanageable than usual. Shortly — that is, 
in the course of a few days — not only the joint, but the entire segment 
of the limb is greatly swollen. This swelling may be the first thing to 
attract attention. The parts are found tense but cool, and devoid of 



452 



DISEASES OF THE CORD PROPER. 



redness and tenderness. The swelling is extreme, but not boggy, and 
does not pit on pressure. Movements of the joint and its employment 
in no way inconvenience the patient. In favorable cases, after a little 
time the swelling subsides and all trouble disappears except a little 
thickeniug about the joint and some creaking in the articulation. There 
is, however, a great tendency to the recurrence of aggravated and more 
lasting attacks. In severe cases the swelling does not disappear so 
promptly, but becomes circumscribed about the joint in a more or less 
globular form, and the joint-surfaces as well as the ligamentous struc- 
tures undergo disintegration. Finally, the limb-segments may be united 
only by soft tissues that permit painless motion and circumduction in every 
direction. Added to the joint-changes, we may have spontaneous frac- 
tures, epiphyseal separations, suppuration, and even the protrusion of the 
bones through the skin. Old tabetic joints present merely a bag of 
bone-fragments where articulations were formerly located. 

In 132 cases of tabetic joint disease Kredel found arthropathies 
occurring 21 times in the prodromic or preataxic stage, 38 times between 

the first and fifth year of the disease, 32 times 
from the fifth to the tenth year, and 41 times 
after the tenth year. They occur in 3 or 4 
per cent, of all cases, and more frequently in 
women than in men. 

The localization of joint-disease in tabes is 
mainly in the large joints, but no articulation 
is exempt. Flatow collected 139 cases, in 41 
of which there were bilateral arthropathies. 
The order of frequency was as follows : knee, 
60 ; foot, 39 ; hip, 38 ; shoulder, 27 ; elbow, 
hand, fingers, and maxilla, 4 to 6 times each. 
The plantar arch usually yields, and flat-foot 
is the rule in tabes. 

Upon section of these joints the capsules 
are found dilated, often ruptured, and in old 
cases completely destroyed. The ligaments, 
especially those within the joints, as at the 
knee and hip, are diseased or have disappeared. 
The synovial membrane is thick, rough, and 
often adherent to the surrounding parts ; later 
it may be absent. It may contain bony parti- 
cles and osseous nodules. The joint-fluid is 
thin and clear or yellowish and exceptionally 
purulent or bloody. At first it is abundant, and infiltrates the parts about 
the joint, into which it escapes through the ruptured capsule, and 
accounts in some cases for the great swelling in the limb. It may con- 
tain floating bodies in large number, bony particles, and detritus. 

The ends of the bones and joint-surfaces may be either (1) eroded, 
as is most usual, and greatly reduced in all their dimensions, even to 
the complete destruction of several inches of their length, or (2) may 
present the hypertrophic exaggeration of an arthritis deformans. These 
two types may be combined in the same joint. The rule is that the 




Fig. 194.— Tabetic arthrop- 
athy of right knee, early stage, 
with edema of the entire ex- 
tremity (Souques and J. B. 
Charcot) . 



DISEASES OF THE WHITE MATTER OF THE CORD. 453 

hypertrophic form occurs in the knee, the atrophic variety at the hip 
and shoulder. The disintegration of the joint may be increased by 
intracapsular fractures or by fragmentation of the eroded shafts and 
separated epiphyses. 

Juergens has found that in most tabetics nearly all the joints show 
capsular enlargement, elongation of ligaments, vascular dilatation, and 
some synovial roughening. The preponderance of such joint-disease in 




Fig. 195.— Tabetic feet. 1 and 3 show deformity due to arthropathia disintegration of the tarsus; 2 has a 
perforating ulcer under head of first metatarsal. 

the lower extremities depends, perhaps, upon their more exacting and 
vigorous use, and consequent liability to strains and traumatism and 
upon the major lesions of the lumbar cord. 

Trophic Cutaneous Disorders. — In tabes there are a number of 
trophic dermatoses that are of rare occurrence and insignificant import- 
ance. Herpes zoster is of more frequent appearance, and finds its fav- 
orite location on the trunk, rarely in the distribution of the trifacial. 
The epidermis of the extremities, especially the upper ones, is sometimes 
hypertrophic. Hyperidrosis, anidrosis, and the loss of nails or teeth 
have been occasionally noted. 

Perforating ulcer is not an uncommon accident in tabes, and, though 
painless, is of considerable importance. It is usually situated in 
the foot, but may occur in the hand, and some authors have conceived 
that maxillary and even cardiac and visceral ulcerations were in some 
instances of the same character. It usually begins as a callus or corn 
on the sole of the foot, under the ball or under the base of the fifth 
metatarsal, or at the heel. Ulceration follows, and, if neglected, may 
denude bone and lead to exfoliation. The ulcer is indolent, persistent, 
and refractory to any treatment if pressure be not removed. Not un- 
commonly the toe-joints or those of the foot present dystrophic condi- 
tions at the same time. Bedsores only appear in terminal stages, and 
present nothing of a special nature. After an attack of lightning pains 
the part in which they are principally located may sometimes present a 
more or less distinct ecchymosis or edema. 

Muscular Atrophies. — In addition to the invariably diminished 
muscular tone that has already been mentioned, and the rare occurrence 
of fracture of a tendon, some tabetic cases present notable amyotrophia. 
This should be sharply distinguished from the emaciation, flaccidity, and 
incoordinate feebleness that are very common in advanced tabes. As 
a rule, the muscular masses and contours are well preserved until the 



454 DISEASES OF THE CORD PROPER. 

ataxia is well developed, and often until the patient has for long been 
unable to walk, but in rare cases, perhaps in one per cent., localized 
muscular atrophy appears. Its common seat is in the lower extremities, 
especially invading the foot- and leg-muscles, and is usually bilateral. 
The upper extremities may be invaded, particularly the small muscles 
of the hands, or even the forearm, arm, and shoulder. The cranial 
nerves are sometimes similarly affected. The motor portion of the 
trifacial and the hypoglossus are the ones usually selected. 

The onset of such amyotrophies is usually insidious. They present 
variously modified electrical reactions, the full reaction of degeneration 
being rare. Once established, the muscular atrophy of tabes remains 
fixed, and does not invade group after group of muscles, as do various 
progressive amyotrophies, but in very rare cases a rapid and extensive 
general muscular atrophy is encountered that reduces the patient to 
skeletal proportions and total disability. The resulting deformity in the 
foot is due to pure, flaccid atony without contracture. The foot drops 
by its own weight and the pressure of bed-covering into an equino- 
varus. In the hands some clawing may be induced and the thenar 
eminence is likely to disappear. Hemiatrophy of the tongue follows 
hypoglossal involvement. 

In a general way, according to Marie, tabetic muscular atrophies 
may be divided into two groups : (1) Those appearing at an advanced 
period of the disease, presenting a symmetrical distribution, rarely 
marked by fibrillary twitchings ; (2) those occurring often in the earlier 
stages of the disease, usually unilateral in distribution, and marked by 
fibrillary contractures and sometimes by the reaction of degeneration. 
The first group embraces those atrophies confined to the distal portions 
of the lower or upper extremities, and recalls the conditions found in 
multiple neuritis. The second group contains lingual hemiatrophy, 
localized atrophies of the shoulder, of the back, of the hand, and one- 
sided involvement of cranial nerves. They are analogous to lesions of 
the nuclear gray matter. Both the central and peripheral lesions are 
found, and in the associations above indicated. The wasted muscles 
present the usual histological change, due to degeneration in the lower 
motor neuron. 

Cerebral Disturbances. — In addition to the vascular cerebral acci- 
dents, with resultant palsies and the involvement of cranial nuclei, 
tabetics are subject to other cerebral disorders. These embrace the many 
possibilities of cerebral syphilis, and particularly paretic dementia. 
Apoplectiform and epileptiform attacks, or any unusual forgetfulness, 
exhilaration, expansiveness, or stupor should at once arouse suspicion of 
this fatal cerebral disorder. It should be studied in this connection, 
and is set forth in the second part of this work. On the whole, nota- 
ble psychical disturbance is a rarity, but some degree of apathy, of in- 
difference, is usually to be observed. This pertains particularly to 
themselves, their disease, their almost hopeless prospects. It is not 
much modified, even by the most atrocious suffering, and persists even 
in the stage of complete helplessness. Tabetics, however, often mani- 
fest large mental activities and retain their business capacity to the end. 

Tabulation of Tabetic Symptoms. — The following table of tabetic 



First 


Second 




Symptom. 


Symptom. 


Total. 


283 times 


65 times 


348 times 


90 " 


119 " 


209 " 


78 " 


113 " 


191 "■ 


74 " 


10 " 


84 " 


34 " 


44 " 


78 " 



DISEASES OF THE WHITE MATTER OF THE CORD. 455 

symptomatology is that of Limbach, 1 based upon 400 cases selected 
from the private practice of Professor Erb. 

In the first table the usual early symptoms are arranged in their order 
of frequency. There is an overlapping, as frequently two or more are 
alleged to have come on at or about the same time : 

Early Symptoms or Tabes. 



Lancinating pains 

Cystic weakness . . . . 

Feeling of weakness in legs . - 
Paresthesia in legs ...... 

Girdle sensation 34 

The relative frequency of various objective and subjective symptoms 
as observed in these 400 more or less complete histories is shown in the 
following table : 

Relative Frequency of Tabetic Symptoms. 

Pee ce>~t. 

.. f (a) Failure of knee-jerk and Achilles jerk 92.0 ) qfi „- 

( (b) Alteration in these reflexes 4.25 j ^ 

2. Swaying with eyes closed 88.75 

3. Lightning pains 88.25 

4. Disturbances of the bladder 80. 5 

5. Ataxia of the lower extremities 74. 75 

6. Changes in the pupillary reactions 70.25 

7. Paresthesia of lower extremities 64. 5 

8. Feeling of weakness in the legs < 62.25 

9. Diminution or disappearance of sexual desire 58. 25 

10. Alterations in size of pupils 48.25 

11. Delayed conduction of pain . . = 36.5 

12. Slight analgesia of lower extremities 33.75 

13. Girdle sensation 31.0 

14. Transitory double vision . 26. 5 

15. Diminution of sense of touch on lower extremities 23.25 

16. Paresthesia in ulnar distribution 16.5 

17. Ocular paralyses and ptosis 16.0 

18. Optic atrophy . 6.75 

19. Persistence of painful impression in the legs 6.0 

20. Various crises 5.25 

21. Arthropathies 1.75 

Course and Varieties. — Ordinarily speaking, the onset of tabes is 
extremely insidious and its course very slowly progressive. For purposes 
mainly of description it may be divided into the preataxic, the ataxic, 
and the paralytic stages. These indefinitely blend, and, as has been 
repeatedly indicated, many symptoms, commonly of the later periods, 
may appear precociously in the early phases of the malady. From the 
tabulation of symptoms, as well as from their individual description, it 
will have been noted that pains are among the earliest indications of 
tabes, and these may persist for years, even for a dozen years, before 
the prominence of other symptoms determines their character. Usually 
only when visceral crises, vesical weakness, ocular palsies, insecurity 
upon the legs, or inability to walk in the dark or down a stair or to 
stand securely while washing the face have seriously attracted the 
1 "Deutsch. Zeit. f. Nervenheilk .," 1895. 



456 DISEASES OF THE CORD PROPER. 

patient's attention is a properly directed investigation instituted. 
Then his "rheumatic pains/' his "gouty pains/' his "neuralgic 
attacks," his "bilious attacks/' take their proper place. At that time 
a search of the cutaneous sensibility usually reveals its impairment in the 
feet and legs, the knee-jerks are absent, the pupils sluggish or inactive 
to light, and the ataxia can be demonstrated by the usual tests. In 
certain rare benign cases the disease never progresses beyond this point. 

In the second period the ataxia increases and is apparent at a glance, 
but may be practically confined to the lower extremities for from two 
to six years or more. Then it may invade the upper extremities pro- 
gressively. A host of sensory, motor, trophic, and visceral symptoms 
are present, varying in every case but usually consistent and uniform 
in the given instance. Even at this point the disease may halt in its 
progressive course. Usually the lack of motor control becomes greater 
and greater, walking more and more laborious, the ataxia intensified, 
and finally the patient is brought to the bed or chair in the third 
period of the disease. Now accentuation of intestinal and especially of 
vesical disturbance and the depreciation of the general physical state, 
taken with the helplessness, make the picture pitiful indeed. All its 
colors may be deepened by the atrocious pains that sometimes pursue 
the unhappy victim to the last. Cystitis looms as a constant menace 
to life, and any intercurrent affection is likely to be promptly fatal. 
From ten to twenty or thirty years may be consumed in the history 
of tabes or it may unroll its panorama of symptoms within two or 
three. 

Tabes presents numerous variations from the wide symptom group 
that may be considered its common type. The cervical form presents 
pain and ataxia first in the upper extremities, which may also show 
trophic changes. Little static ataxia or incoordination of locomotion 
may be presented. The knee-jerk may even be retained, but that is rare. 
In the bulbar form we encounter early symptoms on the part of the 
cranial nerves, pharyngeal and laryngeal crises, optic atrophy, and 
ocular palsies. The tendency of ataxia to disappear upon the appear- 
ance of optic atrophy or for the disease to then become stationary 
furnishes a definite group of cases. 

From another view-point, cases may be considered benign and grave. 
As has been indicated, the tabetic process may stop at almost any point, 
or after a lapse of years may again slowly advance. Some cases that 
are marked by intensely painful manifestations seem to be of slow 
evolution. This may be a way of saying that cases presenting a pro- 
tracted first and second stage, to which the lightning pains and intense 
crises are usually confined, less rapidly disable the patient. On the 
other hand, cases of tabes are grave by the rapidity of their develop- 
ment and the intensity and generalization of their symptoms, due to the 
wide-spread underlying sclerotic process. Acute cases may confine the 
patient to bed in a few months. Leyden describes cases of extreme 
rapidity. Many times after a long, nearly stationary period there is a 
sudden increase of ataxia not attributable to any physical cause, or again, 
undoubtedly induced by strain, trauma, or illness. Any patient con- 
fined to bed for a few weeks is likely to be made much more ataxic by 



DISEASES OF THE WHITE MATTER OF THE CORD. 457 

such restraint. Active syphilitic processes in brain and cord may take 
place, and the patient be overthrown at once. A marasmic state or the 
appearance of paretic dementia constitute conditions of extreme gravity. 

Juvenile tabes occurring in youth between six and twenty-six 
years of age, in the subjects of parental syphilis generally, very much 
less frequently secondary to early syphilitic infection, is a tolerably rare 
form of this disease. Such instances commonly also show a neuropathic 
makeup or inheritance. Hirtz and Lemaire 1 show from a study of 47 
cases as recorded in the literature that some clinical peculiarities are 
commonly encountered . The malady usually begins with urinary troubles, 
less frequently with lightning pains, least frequently with amblyopia. 
Gastric and intestinal crises early are frequently noted . The incoordination 
is relatively slight and tardy in appearing, marked ataxia is unusual. Pu- 
pillary signs and abolition of tendon reflexes occur with the same frequency 
as in adult cases. Lasarew, 2 following von Halban, calls attention to 
migranous headaches as of frequent occurrence in the early periods. 
The clinical type is not infrequently obscured by the presence of active 
or gross syphilitic lesions of brain and cord, by mental and physical 
defects due to the same cause, or by bodily infirmities to which such in- 
dividuals are liable. The stigmata of hereditary syphilis can usually be 
easily noted. 

Diagnosis.— The diagnosis of tabes in the full blown ataxic stage 
rarely presents any considerable difficulty. Confusion usually arises by 
mistaking other diseases for tabes and in misinterpreting the early 
manifestations of tabes for those of slighter ailments. Gastric, laryn- 
geal, intestinal, vesical, urethral, and all visceral crises, if present in the 
preataxic period, are almost invariably referred to the wrong source. 
Their repetition without clearly competent exciting cause or local lesions 
should always arouse suspicion of posterior sclerosis, which, if present, 
will not fail to present other symptoms and signs. The same is true 
of repeated attacks of severe pains of a lancinating or lightning-like 
character. The occurrence of these in a patient where syphilis is even 
suspected to have been present should direct attention to the spinal cord. 

If the knee-jerks are gone or very unequal, or even greatly reduced, 
it should add to the suspicion of tabes. In early cases the condition of 
the heel-jerks is often of significance, as they tend to disappear even 
before the knee-jerks are affected. If, now, the Robertson pupil is 
detected, or even sluggishness of the pupil to light is clearly made out, the 
diagnosis may be considered established. The detection of several 
or many of the usual subjective and objective features of the disease 
will confirm it. Among these, too much importance can not be given 
to vesical disturbances and variations in the sexual sphere. The de- 
termination of lymphocytosis of the spinal fluid and Noguchr's globulin 
reaction; cholin in the blood, and the Wassermann positive in blood or 
spinal fluid, all have great significance in doubtful cases. 

The condition most usually mistaken for tabes is multiple neuritis. 
The differential indications are tabulated on page 333. Unfortunately, 
a group of maladies of a similar, if not identical, character with multi- 
ple neuritis has been denominated pseudotabes. We thus encounter 
1 "Rev. Neurologique," March, 1905. 2 "Neurolog. Centralb.," Nov. 16, 1905. 



458 DISEASES OF THE CORD PROPER. 

cases described as toxic pseudotabes or neurotabes, due to alcohol, arsenic, 
or other poison, diabetic pseudotabes, neurasthenic pseudotabes, and 
syphilitic pseudotabes. They often present the symptoms of multiple 
neuritis, with unusually severe root pains, ocular disturbances, or other 
symptoms that suggest tabes. The absence of well-marked crises, of 
the Robertson pupil, of sphincteric weakness, of pure incoordination 
without paresis, and the history of the onset of the disease, the uniformity 
and invariability of sensory symptoms, the history or presence of the 
toxic cause, and the usual early presence of some muscular wasting and 
the reaction of degeneration should distinguish pseudotabes from pos- 
terior sclerosis. 

Paraplegias are marked usually by definite areas of dysesthesia, the 
reflexes are exaggerated, and clonus common, unless the cord is com- 
pletely divided, when all motion below the lesion is abolished. This 
is not the case up to the last moment in tabes. 

Cerebellar tumor may present some analogy at first sight, but usually 
we have choked optic discs, increased or merely reduced reflexes, intact 
sensibility, retracted head, and occipital pain. 

Insular sclerosis presents some symptoms found in tabes, but is dis- 
tinguished by the intention tremor, nystagmus, scanning speech, usually 
preserved and often increased knee-jerks. The sensory disturbance 
and painful manifestations are insignificant. 

Syringomyelia usually affects the upper extremities first, and may be 
mistaken for cervical tabes. The dissociation of cutaneous sensibility is 
its chief characteristic, but even this has been found in tabes. Scoliosis, 
mutilations of the fingers, local atrophies occurring early in the disease, 
without incoordination and usually with increased knee-jerks, taken 
with a full history of the case and the careful delimitation of the sen- 
sory disturbances, should make the diagnosis exact. 

Finally, a careful examination of the spinal fluid withdrawn by 
Quincke's puncture may furnish conclusive evidence. 

Prognosis. — The diagnosis of tabes largely conveys the prognosis. 
When the degenerate changes that constitute the so-called sclerosis have 
taken place, restitution ad integram is, as far as now known, out of the 
range of possibilities. While, as a general rule, the disease is a 
steadily progressive one, there are many exceptions. In the enumeration 
of varieties of tabes attention was called to the benign cases and the 
possibility of the degenerative changes coming to a standstill at any 
period of development. This renders it the more difficult to estimate 
the value of medication. It has also been indicated that when optic 
atrophy appears the locomotor difficulties usually do not increase. The 
rate of advancement of the disease from its inception is some index of 
the rapidity of its future progress. Bulbar symptoms and the indica- 
tions of developing paretic dementia at once render the outlook most 
gloomy. The duration of life is not, however, abridged as much as 
might be supposed. Marie and Moguot, 1 on a basis of 66 patients who 
had died at the Bicetre, found that 55 had passed the fiftieth year and 
34 had lived beyond sixty. The cause of death is usually some inter- 
current affection not necessarily associated with tabes, though vesical 

1 "Sem. Med.," 1903. 



DISEASES OF THE WHITE MATTER OF THE CORD. 459 

inflammation and secondary infection of the kidneys are always to be 
apprehended. 

Treatment. — In the management of tabes dorsalis it is well to keep 
in view exactly what may be accomplished. The retardation of the 
disease, or, better still, its complete arrest, constitutes a medical victory. 
Given the natural tendency of the disease to halt temporarily in occa- 
sional cases or to come to a permanent standstill, we must be chary of 
attributing too much importance to any line of medication. The intel- 
ligent purpose of treatment is : (1) To arrest any active syphilitic process 
that may be present ; (2) to improve the general health ; (3) to increase 
the nutritive condition of the cord ; (4) to maintain as complete muscular 
control as possible, and (5) to meet the host of incidental disturbances 
as they arise. 

While the role of syphilis in tabes is chiefly played in the past tense, 
it not rarely happens that active and manageable syphilitic lesions attend 
at least its early stages. Meningitis, myelitis, neuritis, and cerebral con- 
ditions or affections of the osseous system may declare themselves, and 
yield to antisyphilitics. The actual presence of the spirochete in the 
lesions of tabes gives substantial reason for antisyphilitic medication. 
Numerous French and German writers have strongly recommended 
intensive mercurial treatment with alleged good results in arresting 
or improving the disease. Intramuscular injections of soluble or in- 
soluble preparations of mercury are used. Brockhart 1 thus treated 
58 early cases, securing improvement in 33 and recession of the disease 
in 12. Lemoine, Devy, and Lerride have had similar results. The 
author feels confident that he has arrested optic atrophy in several 
advanced cases by this method. Salvarsan, with or followed by mer- 
cury, may be used as long as Wassermann's blood test gives a positive 
reaction. The intradural administration of neosalvarsan, either by 
the autoserum method of Swift and Ellis, of the Rockefeller Institute, 
or some of its modifications, gives hope of more efficiently reaching the 
spirochetal than can be done by intravenous or intramuscular routes. 
The iodids are not recommended or used by the author at any stage of 
tabes. 

The general health, with all the conditions of hygiene, good air, and 
a proper diet that pertain to it, are worthy of painstaking attention. 
Not only does a good general state tend to retard the activity of tabes, 
but it protects the patient from the great dangers of intercurrent affec- 
tions, especially of the acute variety. The patient must guard against 
physical strains and exhausting effort of every sort. 

The local nutrition of the cord and spinal apparatus may possibly be 
improved by increasing its blood-supply. This may be mechanical ly 
effected by spinal stretching. It is not desirable to carry this out, as 
first was done, by hanging in the Sayre apparatus — a proceeding that is 
attended by a number of dangers. It can be effectively accomplished 
by having, after Benedict's suggestion, the patient fully flexed upon him- 
self. Tourette and Chipault 2 have proved that the lower portion of the 
cord may actually be stretched by the forward bending of the trunk. Care 

1 " Monatsh. fur praktische Dermatol.," 1902. 

2 " JSouv. Icon, de la Salpetriere," June, 1897. 



460 DISEASES OF THE CORD PROPER. 

must be exercised not to overstretch the patient at first, as the thigh and 
back muscles may easily be severely strained. Gradually, in the course 
of a week or two, through daily seances, the full body flexion, and con- 
sequent extension of the cord, can usually be attained without incon- 
venience. The flexed posture is to be maintained for two or three minutes 
only, and may be utilized night and morning. It often favorably modi- 
fies the lightning pains, and sometimes increases the sexual aptitude. 
The stretching is accomplished by seating the patient on a low table or 
on the floor, with the lower limbs extended. The head is then forcibly 
depressed toward the knees, which are not allowed to bend. The posi- 
tion is to be maintained not to exceed two minutes. Patients, after a 
little instruction, can carry out this plan themselves. 

Local measures to the back, such as deep massage and very vigorous 
slapping, are of similar benefit to the deeper circulation. For this pur- 
pose a broad, stout piece of leather on a short handle may be used to 
vigorously flagellate the back. Its similar application to the soles of 
the feet and on other paresthetic or analgesic regions is useful. Counter- 
irritants along the spine have a certain value, perhaps only an insigni- 
ficant one. The best application is by the thermocautery of Paquelin, 
repeated every seven or ten days. An intense white heat should be 
used, and small dots quickly and lightly made at intervals of an inch or 
two over the portion of the cord principally affected. They may with 
propriety be extended over the course of the nerves where the lightning 
pains discharge. Six, eight, or ten such cauterizations may be followed 
by two or three months' rest, and then repeated. Cold spinal douches, hot 
needle douches, or steam douches to the back are of comparable utility. 

It is only of late that the value of exercises and practice to reestab- 
lish coordination has been recognized. On the other hand, inactivity 
and disuse promptly accentuate the loss of muscular control. The pur- 
pose is not to accomplish feats of strength, and all strains and decided 
fatigue are to be sedulously avoided. Patients must be encouraged to 
faithfully and intelligently practise such movements, motions, and steps 
as are particularly uncertain. In this way they may sometimes be 
brought to stand and to walk with closed eyes after static ataxia has 
been well marked. As many ataxics experience no feeling of fatigue, 
watchfulness on the part of the physician is imperative. It is a point 
of practical importance to see that the patients have proper shoes that 
support the yielding and frequently badly broken tarsal arch. Frankel x 
gives the following exercises, which are of two classes — those performed in 
and those performed out of bed, depending on the patient's helplessness : 

In bed, the patient is called upon to flex, extend, abduct, and aclduct 
each leg separately and then both simultaneously. The knees and hips 
are likewise exercised. The patient is asked to place the heel of one 
foot on the big toe of the other foot, to place the heel upon the knee of 
the other leg, and then slowly travel along the ridge of the tibia toward 
the ankle. Exercises are made alternately, first with one leg, then with 
the other, with open and with closed eyes. These exercises are attempted 
over and over again, with frequent rests. The patient is encouraged to 
persevere until he succeeds. 

1 " The Treatment of Tabetic Ataxia," Phila., 1902. 



DISEASES OF THE WHITE MATTER OF THE CORD. 461 

The exercises are repeated twice a day, a half hour in the morning and 
again a half hour in the afternoon if the patient's condition justifies it. 

1. Patient is placed with his back to a chair, heels together, then 
seats himself slowly in the chair, and is then made to rise in the same 
careful manner. No cane is used. If patient can not stand, an attend- 
ant is placed on either side to support him if necessary. 

2. One leg is placed at an ordinary walking step in front of the 
other, and then placed with great exactness back into its original posi- 
tion. Same exercise is then performed with other leg. The patient, if 
necessary, supports himself by a cane or otherwise. 

3. Walks three paces slowly and with precision. 

4. Rest in standing position, one foot before the other ; with hands 
placed akimbo he flexes his knees and slowly raises himself again. 

5. Patient, as in exercise number 2, advances one foot, then returns 
it to its original position, and then places it one step behind the other. 
This exercise is usually a very difficult one, requiring, as it does, a great 
deal of balancing power. 

6. Walk twenty steps as in exercise number 3. 

7. Number 2 performed without a cane. 

8. Stand without a cane, Avith feet placed together and hands on hips. 

9. Stand without a cane, feet separated ; various movements with 
the arms, grasping objects, forcing back outstretched hand of physi- 
cian, etc. 

10. Maintain same position as in number 9, flexing trunk forward, 
backward, to the right, and to the left. 

11. Exercise number 9 with the feet together. 

12. Exercise number 10 with feet together. 

13. Walk along a painted line on the floor, patient supported by a 
cane. 

14. Same without a cane. 

Exercises for the fingers and arms are also employed, based on the 
above-mentioned principles. 

These various exercises are to be progressively attempted and perse- 
vered in as coordinate strength improves. They may then be gone over 
again with closed eyes aided by a cane or assistant, then without aid. 
Fatigue, however, must be avoided. In advanced cases that have to rely 
on crutches, a tall " walking-frame " or roller-crutch, such as is used 
for children, may be employed. This gives support under the arms 
and enables the patient to exercise the legs. Precise, delicate motions 
with the fingers may also be developed in the same way. The employ- 
ment of an intelligent masseur has given good results in some instances, 
as he can, by the use of graduated resistive movements, teach the 
patient precision in the use of his legs. The so-called home bicycle 
trainer has also given some assistance. On this the patient can pedal 
for a few minutes at a time, and the mechanism carries his feet and legs 
in definite curves. 

In the pre-ataxic stage the patient should walk, stand, and balance 
on each foot, with closed eyes. Daily exercises of this simple character 
seem notably to retard the appearance of locomotor incoordination. 
Women are much less troubled than men in the control of the legs and 



462 DISEASES OF THE CORD PROPER. 

feet, as a rule, and this may be due to wearing skirts, which prevents 
the use of the eyes in guiding the steps. The lack of ataxia in the early 
blind cases is also significant in this connection. 

Eegarding internal medication directed to the sclerosis, mercury, 
arsenic, silver, chlorid of gold, salts of zinc, strychnin, aconitin, atropin, 
and a multitude of others may be mentioned, but aside from some gen- 
eral tonic properties it is difficult to attribute any value to them. Ergot, 
first employed against a hypothetical chronic inflammation in which the 
sclerosis was supposed to consist, has proved itself of some value in 
controlling vesical disturbance, and against this feature of tabes may be 
employed, with precautions to avoid ergotism. Charcot's plan Avas to use 
it the first three days of every week, or it may be used on alternate 
weeks for one or two months, then a long interval and a repetition. It 
should be used in good-sized doses once or twice a day. 

Against the vesical iceakness, especially the sphincteric weakness, the 
method of Brandt to increase the strength of the pelvic floor is of ser- 
vice in tabes. The movements principally useful consist of having the 
patient, while lying on the back, separate and adduct the knees against 
resistance from two to twenty times twice daily, at the same time vigor- 
ously drawing in the pelvic floor and body outlets, and in massage of the 
perineal muscles. 

For the pains of tabes and the visceral crises morphin is sometimes 
required, but the physician alone should administer it, to prevent the 
formation of a habit, and then only as a last resort. Ice, hot applica- 
tions, sinapisms, and the coal-tar sedatives should be first thoroughly 
tried. Of the synthetic preparations, phenacetin and aspirin seem the 
most efficient. Blisters and the cautery to the painful region and over 
the corresponding portion of the cord are sometimes promptly helpful, 
but must be used with circumspection, as healing is often faulty. Re- 
section of the posterior roots of the seventh to tenth dorsal nerves in 
otherwise unmanageable cases of continuous gastric crises have been 
favorably reported by Foerster and Kiittner, Bruns and Sauerbruch, and 
also in this country. Similar operations may be considered as a last 
resort in critical attacks elsewhere situated. 

Tabetic joints are best let alone. Nothing is to be gained by cutting 
operations, and very little by fixation apparatus except such as enable 
the patient to walk. Perforating ulcer is sometimes cured by stretching 
the nerve to the part. 

Cystitis must be guarded against. If it develops, it must be carefully 
combated, and self-catheterization may have to be taught the patient. 
Urotropin - in ten-grain doses, twice or thrice daily, may be employed 
for indefinite periods to keep the urine aseptic and prevent cystitis, but 
sometimes irritates the kidneys. 

The management of the individual will often be found as difficult as 
that of the disease. He must not expect too much, but the physician 
must remember that he is human, and do what he can to encourage and 
cheer him in the face of his distressing affliction, and to insure his faith- 
ful attention to the numerous small and exacting details of treatment. 

The appearance of any active syphilitic process demands prompt 
recurrence to specific treatment. 



DISEASES OF THE WHITE MATTER OF THE CORD. 



463 



COMBINED SCLEROSES OF THE SPINAL CORD. 

Occurring, perhaps, as frequently as tabes, many cases of or- 
ganic cord-disease present symptoms referable to the simultaneous in- 
volvement of the lateral and the posterior columns, which are found 
sclerosed in widely varying proportion. This condition is termed ataxic 
paraplegia by Gowers, progressive spastic ataxia by Dana, and is known 
variously as posterolateral sclerosis, combined posterior and lateral scle- 
rosis, and combined tabes, or sometimes as spasmodic tabes. Some cases 
show a tolerably definite limitation of the sclerosis, suggesting a sys- 
tematic degeneration, but usually it is not strictly confined to the physio- 
logical tracts of the cord. For the most part the lesions are within the 
posterior half of the cord's cross-section, and are commonly embraced in the 
posterior arterial field (see p. 345 and Fig. 126) . Occasionally the lesion also 
encroaches upon the peripheral portion of the cord in front, which belongs 
to the anterior arterial field. The symptoms are dominated by ataxia and 
spasticity, and the tendency is progressively toward paraplegic helplessness. 

Etiology. — The causes of combined sclerosis are numerous. ^It must 
be at once recognized that this extensive symptom group is frequently 
a secondary cord-process: (1) In a certain small number of cases, 
primarily tabetic, a diffuse myelitis also invades the lateral tracts; (2) it 
is found more frequently in 
general paresis than are lesions 
entirely confined to the pos- 
terior columns; (3) a diffuse 
myelitis gives rise to ascending 
and descending degenerations 
that furnish a posterolateral 
sclerosis; (4) leptomeningitis 
may entail a marginal myelitis 
that invades the periphery of 
the cord and principally affects 
its posterior half; (5) vascular 
lesions, affecting principally 
the posterior field, induce a 
sclerosis in the posterior and 
lateral tracts ; (6) pellagra some- 
times causes a combined pos- 
terolateral sclerosis; (7) toxic 

conditions, as in the pernicious anemias, may cause it ; (8) the postero- 
lateral sclerosis may be evidence of an embryonic deficiency as in 
Friedreich's ataxia. 

There is frequently a history of antecedent syphilis or one of expo- 
sure to cold, traumatism, concussion, or muscular strains. Sometimes 
acute infections lead to it. It is much more common in males than in 
females, and usually appears between twenty-five and forty years of age. 

Morbid Anatomy. — The sclerosis implicates both the lateral and 
posterior columns, but sometimes one, sometimes the other with greater 
intensity. The columns of Goll, usually commencing above the lumbar 
enlargement, are degenerated to the medulla. The columns of Burdach 




-Combined posterolateral sclerosis. Scheme 
usual area of cord-change limited to the pos- 
terior arterial field of the cord (Brissaud). 



>howii 



•464 DISEASES OF THE CORD PROPER. 

are also affected mainly above the lumbar enlargement, but less in- 
tensely, and the root-zone usually escapes. The crossed pyramidal tract 
is, as a rule, partially affected, its inner portion being customarily 
spared. Its lesion is slight in the cervical region, and increases in the 
lower dorsal and lumbar portions of the cord. The direct pyramidal 
tract is only affected when the lesions are intense in the upper cervical 
region, and even then but slightly. The direct cerebellar tract is always 
intensely affected. The ascending tract of Goicers sometimes escapes, 
sometimes is partially affected. The gray substance is usually intact. 
.Rarely the anterior cornual cells or those of the posterior horn or of 
Clarke's column mav be slightly modified. 

The sclerotic areas differ from the degenerated portions of a tabetic 
cord in presenting hypertrophied axes-cylinders, many spider-cells, and 
notable changes in the blood-vessels. The alteration in the nervous 
tissue is also proportionate to the vascular lesions and most intense in 
their neighborhood. Occasionally a chronic meningitis is present. 
Cranial nuclear involvement has been found in some cases. 

To sum up, the lesion is of a myelitic character rather than that of 
a pure parenchymatous Wallerian degeneration. It affects the posterior 
columns from the lower dorsal area upward and the lateral tracts from 
the cervical region downward in increasing intensity, precisely as do 
secondary degenerations. The lesion is indiscriminate in localization 
and bears a close relation to the arterial supply of the part. 

Symptoms. — The symptoms of the combined scleroses are those 
of spastic paraplegia and locomotor ataxia variously combined and 
associated. One case shows a preponderance of ataxia, another of spas- 
ticity, depending upon the distribution and intensity of the lesion in 
the posterior or lateral columns and upon its vertical extent. Lesions 
of these tracts give us, on the part of the posterior columns, incoordi- 
nation, an ataxic gait, Romberg's sign, diminished or lost reflexes, lan- 
cinating pains, anesthesias and paresthesias, ocular symptoms, vesical and 
genital derangements, etc. Eelated to the lesion of the lateral tracts 
we have exaggeration of tendon reflexes, foot-clonus, Babinski's toe- 
sign, motor enfeeblement, cramps, spasms, and the spastic gait. By 
their association in posterolateral sclerosis we usually find ataxia and 
spastic weakness, with increased tendon reflexes, well marked in the 
lower limbs, less pronounced in the upper extremities, and cranial-nerve 
symptoms are seldom entirely absent. 

The onset of the disease, when not due to a diffuse myelitis of more 
or less acute character, is insidious. One of the earliest complaints is 
that of becoming readily tired in walking, the legs feeling heavy and weak. 
Some ataxia soon presents itself, as is shown by the unstable station with 
closed eyes, or difficulty in turning or walking under the same condi- 
tion. The hxee-jerhs will be found increased in activity and amplitude. 
The cutaneous reflexes may be increased or diminished. The cremaster 
is usually inactive. Muscular weakness can be easilv detected. The 
muscles do not lose their contours and are often firm to the touch, but 
are incapable of strong contraction. The ataxia increases ; the gait be- 
comes very uncertain, with a tendency to sprawling, and at the same 
time it is spastic, so that the feet are not readily brought forward, and 



DISEASES OF THE WHITE MATTER OF THE CORD. 465 

they may be shaken by clonus, which is often easily developed in the 
calf and rectus feinoris muscles. Some vesical weakness is very com- 
monly encountered, and loss of sexual appetite is frequent, though erec- 
tions and even painful priapism may annoy the patient. 

Sensory symptoms are much less common, and when present are ex- 
tremely slight as compared with tabes. Instead of lightning pains we 
find dull aches, usually in the thighs and small of the back and over the 
sacrum. Paresthetic sensations are not uncommon, but actual anesthesia 
or any considerable blunting of tactile sensation is very rare. The 
girdle pain is occasionally present. Visceral crises are not common, and 
are not severe when they do occur. Rectal and vesical tenesmus and 
painful cramps in the legs at night are sometimes the source of much 
complaint, and the corresponding sphincters may be impaired in excep- 
tional cases. There is often inability to satisfactorily empty the bladder 
and bowels. Urinary retention may then lead to cystitis. 

The upper extremities almost invariably show an exaggeration of the 
tendon reflexes, and some rigidity and weakness is not infrequent. An 
exaggerated jaw-jerk may be easily demonstrated in most instances. 
Tremulous twitchings in the tongue and face are not rare, and speech 
ma} 7 be thickened slightly, ei~en in the cases not associated with paretic 
dementia. Pupillary symptoms are not uncommon, but the light-reflex 
is rarely lost when accommodative contraction persists. Inequalities 
of the pupils, irregularities of outline, and sluggishness of motility to 
various stimuli are frequently noted. The mental state is ordinarily 
normal, but there may be some loss of lneruory, dependent, mainly, on 
lack of concentration and attention. Prolonged mental application is 
usually impossible. In short, it is a neurasthenic state. 

As the disease progresses the paresis in the legs and the spasticity 
increase. The static ataxia is also exaggerated actually and also by the 
increased weakness. Finally, the patient is unable to walk and the 
spastic ataxia becomes marked in the arms. The paraplegic state is thus 
induced, but sensory disturbance, as a rule, is insignificant to the last. 

Course. — AVhile the disease is progressive it is much less rapid in its 
course than tabes, and the great majority of cases never become entirely 
unable to walk. Of itself it rarely causes death. Bedsores, cystitis, 
and kidney disease are the chief dangers. Intercurrent affections neces- 
sarily find victims in these devitalized subjects. The cases that com- 
mence as tabes or as myelitis present features referable to their origin. 
Early loss of knee-jerks, the presence of girdle pains, anesthesias, 
analgesias, or joint-lesions with spastic features in the upper spinal 
levels are probably due to myelitic extension from a posterior sclerosis. 
Those presenting rapid onset and girdle features and localized atrophies 
are usually attributable to diffuse myelitis. 

Diagnosis. — The diagnosis of progressive spastic ataxia, which is 
the best descriptive name for this symptom group, depends upon the 
muscular weakness, the ataxia, the spasticity, and the progressiveness of 
the disease. In early stages when the ataxia is prominent it is usually 
mistaken for tabes, but the muscular weakness, the increased reflexes, 
the insignificant sensory disturbance, the absence of girdle pains, and 
visceral crises should at once differentiate it. In later stages when the 

30 



466 DISEASES OF THE CORD PROPER. 

paraplegic features are preeminent the ataxia is lost in the motor extinc- 
tion, but a history of it can usually be obtained. Cross or focal lesions 
are now sometimes thought of. The sensory integrity and the presence 
of symptoms in the arms and in the cranial nerves should serve to 
exclude such limited lesions. The family ataxias present a somewhat 
similar symptomatology, and the cord-lesion has about the same distribu- 
tion. The familial features, the nystagmus and articular disturbance, 
its occurrence in early life, and in the type of Friedreich the absent 
patellar reflex, should make the diagnosis plain. Cerebellar tumor can 
induce ataxia, increased knee-jerks, and weakness in the legs, but also 
usually has vomiting, occipital pain, choked disc, and retracted head, and 
may have forced attitudes or movements to distinguish it. 

Prognosis. — The slowly progressive tendency of the disease has 
been sufficiently insisted upon. Stationary periods, or those compara- 
tively so, are very common, and even improvement in the individual 
features of some cases are not infrequent. Complete relief, in the nature 
of things, is an impossibility, and the onward course of the paretic and 
spastic features is taken up sooner or later. Mental disturbance, while 
uncommon, may appear and paretic dementia ensue. Every case is to 
be judged by itself. The rapidity or slowness of development in the 
early years of the malady is likely to mark it throughout. As already 
indicated, only a small portion of the cases reach absolute helplessness. 

Treatment. — The treatment of a case of progressive spastic ataxia 
will be modified by its variety and origin. When secondary to tabes, 
the treatment is the same as in that disease. When syphilis is admitted 
or can be determined by examinations of the blood and spinal fluid, 
continuous antisyphilitic treatment must be pursued, guided by the 
blood tests. Counterirritation over the spine, spinal stretching, and 
exercises to reestablish coordinate motor control are valuable. Thermic 
baths, and hydrotherapy generally, here find a very useful application. 
As a rule, the use of hot douches, sprays, and baths lessen the spasticity, 
but in rare cases cold to the back has the better effect. Massage of the 
muscles and graduated exercises are important, but the fatigue point 
should be carefully estimated and never exceeded. To this end the 
paretic features are the guide, and the sensation of fatigue the criterion. 
Owing to the hyperexcitability of the reflexes, massage sometimes is 
not well borne. General measures looking to the physical health and 
the mental quietude of these patients add to their comfort and to the 
length of life. The bladder condition should receive constant watch- 
fulness, as a high degree of retention may develop without attracting 
the patient's notice. 

COMBINED CORD-LESIONS IN ANEMIAS AND CACHEXIAS. 
Nonne was the first to demonstrate decided changes of the spinal cord 
in cases of pernicious anemia. Somewhat similar changes in the retina 
were well known, and apparently identical degenerations take place in 
the brain. This observer found degenerative changes in the cords of 
ten out of seventeen cases of pernicious anemia though symptoms refer- 
able to the cord had been observed in but two. The changes are prin- 
cipally located in the white matter of the cord, and show a decided 



DISEASES OF THE WHITE MATTER OF THE CORD. 467 

tendency to mainly affect the posterior half, giving rise to a group of 




Fig. 19T 




Fig. 198. 




Fig. 199. 

Figs. 197, 198, and 199.— Sections from three spinal cords showing 

anemia (Billings). 



degenerations due to pernicious 



symptoms referable to the posterior and lateral tracts. In some in- 
stances, however, the anterior portion of the cord and even the gray 
matter is involved. By experimentally induced anemia in the brain 
and cord Massaro, Sciciliano, and Soukhanoff have demonstrated similar 
cellular changes in animals. Teichmueller, Minnich, Lichtheim, in Ger- 
many, Russell, Batten, Collier, in England, Dana, Putnam, Riggs, and 
Billings, in this country, among many others, have not only confirmed 
Nonne's findings, but broadened the general field of known degenerative 



i 



468 DISEASES OF THE CORD PROPER. 

conditions secondary to depraved physical states. The consensus of 
opinion now seems to be that the cord changes are due to a toxic process, 
secondary to many seriously debilitating systemic conditions, acting 
upon a nervous system of deficient attributes, shown either by a marked 
neurotic heredity or by general physical defects. 1 The operation of the 
toxic process is apparently by way of the vascular apparatus, giving rise 
to hemorrhagic or interstitial changes resulting in more or less sclerotic 
transformation. 

Women are affected nearly three times as frequently as men. 

Symptoms usually appear after the age of thirty, most commonly in 
the fourth decade of life. In addition to the features of the anemias 
and cachexias and the conditions arising from these states, there is often 
a decided mental irritability. Atrophy of the optic nerve has been 
observed in some instances. Epileptiform attacks have occurred. 

The symptoms referable to the spinal cord are those of ataxia, spas- 
ticity, and weakness, variously combined, giving rise, as a rule, to 
an ataxic paraplegia similar to that described in the foregoing section. 
Early in the disorder the tendency is to increased reflexes, which later 
tend to subside or may entirely disappear or persist. In some cases the 
knee-jerk is lost early. Girdle sensations are not uncommon. Pares- 
thesia occur from the first and are persistent. Neuralgias are common, 
so that multiple neuritis is often suspected. Bed-sores, cystitis, and 
sphincteric palsy may be encountered in terminal states exceptionally. 

The duration of the disorder is variable. Many cases reach a pro- 
found degree of exhaustion before the cord symptoms develop, in which 
case they are likely to rapidly attain a severe grade. In other instances 
paresthesia, increased reflexes, and motor weakness come on insidiously 
and endure for a number of years, the general physical state being 
relatively but little impaired. In a general way these cases last from 
one to five years, the tendency being steadily for the worse, though 
slight remissions may be encountered. In some instances the paralytic 
and sensory disturbance becomes rather rapidly greater in the lower 
extremities and steadily mounts upward like an ascending myelitis or 
may advance and recede many times. The ultimate outcome is almost in- 
variably fatal, and the prognosis depends mainly upon the systemic state. 

The treatment is that of the anemia or underlying cachexia, the 
secondary toxic conditions, and the resulting changes in the cord. In 
the pernicious types of anemia the use of the newer arsenical prepara- 
tions, particularly the cacodylate of sodium and neosalvarsan, can be 
recommended. Normal salt solution by the drop method into the bowel 
or by hypodermoclysis increases the volume of fluids in the circula- 
tion, washes the blood, and favors elimination of toxins. The disabili- 
ties arising from involvement of the cord have to be met by gymnastics, 
exercises, and massage. 

FAMILY ATAXIA 

In 1861 Friedreich reported several cases of ataxia occurring in the 
children of one family. They presented, among many symptoms, the 
loss of the patellar reflex, incoordination of all four extremities, nys- 

1 Putnam and Taylor, "Jour, of Ment. and Nerv. Dis.," Jan., 1901. 



DISEASES OF THE WHITE MATTER OF THE CORD. 4$9 

tagmus, disturbance of articulation, and a progressive tendency to help- 
lessness. Similar cases have since been reported in every country, until 
hundreds may be collected from the literature. In some instances the 
disease is found to appear in several generations, but, ordinarily, it is 
confined to a single family, and usually appears before adolescence. 
To the symptom group presented by these cases the name of Friedreich's 
disease, or Friedreich's ataxia, has been given. 

In 1880 Fraser 1 reported a series of cases extending through sev- 
eral generations, marked by the same symptoms as occur in Friedreich's 
group, excepting that the reflexes were increased and ankle-clonus some- 
times present. Nonne, in 1891, reported a similar family, and clearly 
pointed out the features in which the cases falling under his observation 
differed from the Friedreich variety, and especially the fact that they 
developed later in life, — namely, during or after adolescence, — and that 
they frequently showed visual defects and optic atrophy. Farly exam- 
inations of Friedreich's form discovered spinal sclerosis, embracing the 
posterolateral area throughout the cord, and a cord of diminutive size 
in some instances. To this, in some cases, is added an undersized cere- 
bellum and cranial-nerve lesions. In one of Nonne's cases only an ex- 
treme smallness of the cerebellum and cord was found. Switalski 2 
reports a case showing diminutive proportions in cord and cerebellum, 
degenerations of Goll's columns, the direct cerebellar tract, Gowers' tract 
and some atrophy of the anterior horn cells. The cerebellum showed 
a diminished number of convolutions, separated by deep fissures, and a 
paucity of white substance. A family very similar to those of Fraser 
and Nonne was reported by Sanger Brown, 3 and autopsy on three of his 
cases showed no gross cerebellar defect. 4 Transition cases 5 are being 
observed that furnish every intermediate variety between the spinal 
cases on the one hand and the cerebellar cases on the other. For the 
latter group Marie has used the descriptive designation pseudoataxie cere- 
belleuse, and hereditary cerebellar ataxia. Senator 6 sees in Friedreich's 
ataxia only the manifestations of teratological cerebellar and spinal defect. 
In the cases of Nonne and others marked by cerebellar atrophy, or, 
more probably, cerebellar agenesis, the same origin is apparent, and the 
variety of clinical cases and anatomical findings seems to depend upon 
the location of the principal defect. Gordon Holmes in a careful review 
of the subject, 7 basing his groups upon definite and carefully investigated 
cases which have been properly examined post mortem, suggests the 
following classification: (1) Primary parenchymatous degeneration of the 
cerebellum. (2) Olivo-ponto-cerebellar atrophy. (3) Degeneration of 
the spino-cerebellar tracts, the cerebellum being normal or small only. 
(4) Congenital smallness of the central nervous system with cerebellar 
symptoms. The familial and hereditary features of these cases at once 
declare their embryonic character and origin. The portions of the cord 
that undergo sclerotic changes are precisely those which are last to develop 
and become myelinated, only reaching completion at the end of the 
ninth or in the tenth month. 

1 "Glasgow Med. Jour.," 1880. 2 "Nouv. Icon, de la Salpet.," Sept., 1901. 

3 "Brain," 1892. 4 Ibid., 1897. 

5 Haushalter, "Rev. de Med.," 1895. 6 "Berlin, klin. Wochens.," 1893. 
7 "Brain," No. 120, 1907. 



470 



DISEASES OF THE CORD PROPER. 



Etiology. — The most important etiological feature of the family 
ataxias is their embryological nature. Why a mother should give birth to 
several children with defective nervous structures or other teratological 
defects it is impossible to say, though phthisis and other exhausting 
cachexia? have presented in some of these parents. As is common in 
familial nervous diseases, there is a tendency to a preponderance of 
males, and the transmission is usually by the female line. Both of 
these points are illustrated in the genealogical diagram of Brown's cases 
(Fig. 200). In a given family there is frequently noted a tendency for 
the disease to be manifest at a progressively earlier age in successive 
children. The symptoms are likely to appear at the developmental 
periods of life. In some cases they are congenitally evident ; in others 
the first or second dentition, the ages of puberty, adolescence, and com- 
plete adult sexual differentiation and reproductive ability seem to make 
demands that the defective neural apparatus can not meet, and there- 
after retrogrades. In exceptional cases the disease appears late in life. 
Friedreich's type usually occurs before the age of fourteen ; hereditary 
cerebellar ataxia, or Marie's form, after pubescence. In many cases, 
especially in children, and, therefore, usually in Friedreich's variety, the 




UT) 



nTTWtt 



~~P C j ^5^. 7otke^ehiLdren. ~? S 



•2*113* 






tl "it 2 ** O 



father children. 



u 



^J 



iswmwAo 



u 




Fig. 200. — Family tree of hereditary ataxia, reported by Dr. Sanger Brown. Explanation of 
diagram: Shaded inclosures indicate hereditary ataxia. Squares indicate males ; circles females. The 
numbers to the left refer to the cases in Brown's paper ; the first number to the right, the age at death 
or the present age. f indicates deceased. The last number indicates the age at onset. 



occurrence of an infectious fever appears to precipitate the symptoms of 
the disease. In these cases, too, the cord-lesions correspond to those of 
the combined scleroses and occupy the posterior arterial field of the cord's 
cross-section. The embryonic vulnerability of this portion of the cord may 
serve to locate the lesions in these instances in the lower levels through 
the intermediary of the vascular supply and the action of toxic factors. 
Morbid Anatomy. — The morbid anatomy of these family ataxias 



DISEASES OF THE WHITE MATTER OF THE CORD. 



471 



varies as the case corresponds to the spinal or the cerebellar type. The 
cases that conform strictly to Friedreich's syndrome show a posterolateral 
sclerosis analogous in distribution to that of progressive spastic ataxia. 
There is a decided sclerosis of the columns of Goll and Burdach, with 
shrinking of the cord in this region throughout its entire length. There 
is sclerosis of the crossed pyramidal tract, of Goicers' tract, of the direct 
cerebellar tract, of Lissauer's tract, and frequently atrophy of the cells of 
Clarke's column. The posterior horn and its cells are shrunken and in 
rare cases the anterior cornual cells are degenerated. Marie insists that 
the changes in the pyramidal tract are confined to the fibers related to the 
direct cerebellar tracts and Gowers' tracts, and do not directly affect the 
upper motor neurons. The portions of the cord that last develop are 
thus affected by the retrogressive changes of the malady. As a rule, 
the cord is undersized and may present only two-thirds of its usual 
thickness. In a few cases, notably that of Menzel, the medulla and 
cerebellum were also reduced in size and degeneration has been traced 
into the cerebrum. The posterior roots and ganglia are usually normal. 







Fig. 201.— Dorsal cord-section in Friedreich's disease, showing distribution and relative intensity of 

sclerotic changes (Marie). 

Rennie, 1 however, found degeneration of posterior root-fibers, and pos- 
terior root-zones. The cranial nerves are generally spared in the spinal 
variety, but the hypoglossus and optic nerves have been found diseased. 

The cerebellar form, in the few cases on record, has presented atrophy 
of the cerebellum, as in Fraser's case, in one of Nonne's, in Switalski's, 
and in Holmes' case. 2 This is absent in Brown's cases, but the cerebellar 
tracts in the cord were involved. This cerebellar atrophy is said not to be 
sclerotic. The gray substance is abnormally thin, Purkinje's cells are few 
in number and undersized, the white matter is less voluminous than usual, 
and the weight of the organ is reduced a third or a half. The cord in these 
cases of Marie's type is undersized, but shows no sclerotic degenerations. 
There appears to be a pure genetic poverty of fibers, or else they have 
disappeared, leaving no trace. In Brown's cases, as reported by Meyer 
and later by Barker, 3 there was degeneration in the dorsolateral cere- 
bellar tract and degeneration in the gray and white matter of the cord, 
medulla, and cerebellum. Optic atrophy is not infrequent. 

Symptoms. — The motor symptoms are the most prominent. They 
commence with clumsiness, especially in walking. The child stumbles 

1 "Br. Med. Jour.," July 15, 1899. 2 "Brain," 1907, No. 120. 

3 "Decennial Pub., University of Chicago," 1903. 



472 



DISEASES OF THE CORD PROPER. 



over every trifle and becomes more and more unsteady on its feet. 
Later the gait is staggering and drunken in its uncertainty. Ataxia 
marks every movement and position, but there is no rigidity even in 
the cases presenting increased reflexes. All movements are clearly 
intentional, though clumsily executed, and have for their purpose to 
maintain the insecure equilibrium. In standing the body is constantly 
swaying, and shuffling steps in various directions are frequently taken 
to maintain the balance. With closed eyes the difficulties of the station 
and gait are not notably increased, and there is practically no loss of 
the muscular sense, only an ataxic incoordination in executing move- 
ments. Frequently coarse, rhythmic, trembling or jerky movements are 
made on attempts to use the extremities, and at rest often a finger 
or the wrist, shoulder, elbow, head, or lower extremity is moved or 
twitched in a spasmodic manner. Such movements are frequently seen 
in the face, especially when the patient begins to talk or when some emo- 
tional expression is called out. Ordinarily, complete support of the part 



1 "k 


AIL 


JL 



Fig. 202.— Apathetic facies in Friedreich's ataxia. 1, 0. F., eight years old, affected one year; 2, F. F. f 
seventeen years old, affected three years ; 3, R. F., twenty years old, affected five years. 

or its complete rest causes them to cease. The head, in a similar way, 
nods in one direction or another, and may, in late cases, roll around on 
the shoulders as if articulated with ball and socket. As the patient 
sits, the body may also sway about above the hips. An examination 
of the muscular strength finds it but slightly reduced, and clearly indicates 
■tfiat there is no serious paralytic state present. The muscles do not 
waste except in cases of long standing, and then only rarely and mainly 
about the shoulders and hands. 

The sensory symptoms have usually been given little attention 
because the superficial elements of touch are not much modified. A 
careful study of sensation in ^20 cases by P. W. Saunders 1 brings out 
the important fact that the elements of sensibility which are sup- 
posed to be conducted through the dorsal columns of the cord are con- 
stantly disturbed, and more especially for the lower extremities. Touch, 
pain, and temperature tests are not much modified, though usually 
reduced to some degree, but the recognition of vibrations, the sense of 
passive movements and position, and the appreciation of double con- 
tacts are greatly diminished. 

The superficial reflexes are not disturbed. In cases of the Friedreich 
type the deep reflexes are diminished or abolished and the knee-jerk 

* "Brain," 1913, p. 166. 



DISEASES OF THE WHITE MATTER OF THE CORD. 473 

usually disappears very early. In Marie's form the deep reflexes are 
exaggerated and foot- and rectus-clonus are commonly encountered. 
The sphincters are unaffected. 

The face presents an appearance of hebetude that deepens as the 
disease advances and in some instances first calls attention to its inva- 
sion. The features droop in a mask-like blankness of expression, 
often intensified by a half-open mouth. In emotional expression 
the ataxic unbalance appears, resulting in contortions, or, at least, 
exaggerations f facial movements. There is usuallv well-marked 
nystagmus. The oscillations of the globe, however, tend to cease if the 
eye is allowed to remain at rest, and vary in amplitude and are increased 
by effort, like all the other manifestations of incoordinate muscular 
balance. It is often necessary to direct the eyes widely from the direct 
line of forward vision to develop the nystagmic jerking. This can 
usually be accomplished by having the patient fix his eyes upon an 
object in an outward and upward direction. Palsies of the ocular 
muscles are extremely rare. Joffrov has published one case, and another 
is illustrated here. In Friedreich's form optic atrophy is a rare excep- 
tion. Small 1 reports three out of four cases in one family showing 
some degree of it. In Marie's form, on the other hand, it is a com- 
mon finding, and changes in the visual acuity and in the form- and color- 
jields are frequently encountered. The pupiUary reflex is usually normal 
in Friedreich's form, but may be affected in Marie's group. 

The speech is ataxic, if the expression may be used. Modulation 
of the voice and prompt enunciation are defeated by the tardy and inco- 
ordinate action of the muscular apparatus. It reminds one of the gait ; 
some words come quickly, others slowly, and the voice tones change 
suddenly and irregularly iu pitch or other qualities, though tend- 
ing to a monotone. The intelligence of these patients is 
not much impaired in the early years of their malady , 
and is often belied by their apathetic and empty faces, 
but in the later stages of the disease the mind is frequent ly 
sluggish or shows some retardation of development. In 
Friedreich's form physical development is also frequently 
retarded if the disease manifests itself before puberty, 
and sexual functions are correspondingly backward. 

Trophic and vasomotor defects are very rarely 
encountered, or are entirely lacking except a 
peculiar conformation of the feet and a slight verte- 
bral scoliosis that are frequent in Friedreich's 
form. The club-foot consists of an exagger- 
ation of the plantar arch which shortens 
the foot notably and causes the toes to 
assume the " hammer" position, extended 
at the first and flexed at the other Fig. 203.— Clubbed foot of Fried- 

ii mi • • 1 1 it- reich's disease, showing shortened arch 

phalanges, this is particularly marked in and retracted great toe. 
the big toe, which usually is first affected 

and is sometimes the first symptom of the disease detected by rela- 
tives conversant with its forms. The deformity is increased when the 
1 "Med. Eec," N. Y., July 20, 1895. 




474 DISEASES OF THE CORD PROPER. 

foot is extended upon the leg, and if slightly marked, may disappear 
when the patient is standing. A similar deformity of the foot is also 
encountered in some of the family and sporadic cases of progressive 
muscular atrophy. The scoliosis appears in most of the well-developed 
cases of Friedreich's form, and occupies the dorsal and lumbar spine. 
It is usually slight. 

Varieties. — The two major varieties making up the group of family 
ataxias have been indicated throughout the preceding pages, and there 
are many authoritative writers who regard them as distinct entities. 
Their principal differences are contained in the following table. The 
cerebellar features clinically predominate in both and autopsies are yet 
too few to justify their complete separation, especially as all inter- 
mediate varieties are being reported : 

Friedreich's Form. Marie's Form. 

Hereditary spinal ataxia appears usu- Hereditary cerebellar ataxia appears 

ally before puberty. usually after puberty. 

Choreic movements in upper extremi- Very common and pronounced. 

ties and oscillations in head and trunk 

frequent. 
Optic atrophy and amblyopia very ex- Common. 

ceptional. 
Tendon reflexes diminished or absent. Increased, foot-clonus frequent. 

Club- toot and scoliosis common. Exceptional. 

Course. — The first symptoms to attract attention, unless the case is 
congenital, are the difficulties in walking. Sometimes certain families, 
who have learned to know the symptoms from the number of cases 
among them, recognize, by the facies or the scoliosis or the club-foot and 
cramped toes, that another member has been added to the list. In the 
course of three to four years the ataxia in all four extremities is well 
marked. It advances and augments and in another similar period takes 
the patient off his feet and renders him practically helpless. In this 
state he may live ten to twenty years and finally die from intercurrent 
disease. While the course of the disease is commonly steadily pro- 
gressive, long remissions may occur and sudden aggravations take place, 
but death does not result directly from the disorder. 

Diagnosis. — The diagnosis of a case of family ataxia is almost self- 
evident if numerous members of the same or succeeding generations are 
affected, but in certain instances no such collateral cases exist. The 
differential diagnosis must then be made from tabes, chorea, and insular 
sclerosis. In tabes the gait lacks the cerebellar quality. Posterior 
sclerosis also presents visceral crises, lightning pains, vesical weakness, 
sensory disturbances, and pupillary symptoms. It is a disease of full 
adult life, has commonly a syphilitic history, and nystagmus is extremely 
uncommon in it. The cases of family ataxia occurring late in life 
usually present increased reflexes. 

From chorea, for which it is frequently mistaken, especially in chil- 
dren, family ataxia may be distinguished by the major affection of the 
upper extremities in Sydenham's disease, its rather abrupt onset, and 
the absence of nystagmus, scoliosis, club-foot, and persistent abnormal- 
ities of the tendon reflexes. Huntington's family chorea of adult life 



DISEASES OF THE WHITE MATTER OF THE CORD. 475 

has its mental features and forced attitudes and movements, which are 
greatly in excess of anything seen in the family ataxias. 

Insular sclerosis presents the closest resemblance to family ataxia, 
especially Marie's form ; and as it also may affect several members of 
the same family, the differentiation may be most difficult, if not impos- 
sible. We must recall its distinctive intention tremor, its lack of static 
instability, its scanning staccato speech, its spastic features and gait. 

Prognosis. — The outlook in these family ataxias is always gloomy. 
Aside from the helplessness there is no suffering, and, as a rule, they 
bear their lot with an apathetic good nature. 

Treatment. — The management of these cases does not promise 
much improvement. Some have thought that spinal stretching and 
electricity improved the incoordination. Carefully planned exercises 
may, perhaps, assist in the same direction. 

HEREDITARY SPASTIC PARAPLEGIA. 

Commencing with Strumpell, groups of cases have been recorded by 
Bernhardt, Philips, South, Xewmark, 1 Achard and Fresson, 2 Bay ley, 3 
and others, which present pure spasticity and familial traits. Bayley 
traced the disease through five generations, the individuals affected 
showing marked similarity in all respects. In his series it seemed 
that the disease once escaped did not reappear in the descendants. 
Spiller 4 reports a family showing the disease in eight generations. 

The spastic condition may appear at any age from the first (Achard 
and Fresson) to the fifty-sixth year (Strumpell) and very commonly 
is preceded by some infectious disease, as typhoid, measles, etc. There 
is paresis only in the terminal stages and no ataxia. The muscular 
hypertonus and increased reflexes are alone noted. Sensory and sphinc- 
teric difficulties are absent and cerebral features are insignificant, or only 
such as are attributable to defects in the intracerebral portion of the 
motor pathway. The leg rigidity may, however, render the gait mark- 
edly spastic and walking finally impossible. 

The symptoms are referable to the pyramidal tracts which, with 
the columns of Goll and the direct cerebellar tracts, were found degen- 
erated by Strurnpell. Erb, 5 who called it a primary spastic paraplegia, 
has collected ten postmortem reports showing the sclerosis to be mainly 
confined to the lateral portions of the cord and principally to the crossed 
pyramidal tract. Jendrassek 6 believes that the process may begin 
in the brain, bulb, or cord, and is introgressive in nature. From the 
familial feature of these cases it is evident that the basis of the para- 
plegia is a teratological defect and its sometimes late appearance is no 
bar to such belief. 

Treatment promises little, though massage and carefully selected 
exercises may accomplish something. 

1 " Med. News," Feb. 10, 1897. 

2 " Gaz. hebdom. de Med. et de Chir.," Dec., 1896. 

3 "Jour. Nerv. and Ment. Dis.," Nov., 1897. 

4 "Phila. Med. Jour.," June 21, 1902. 5 " Br. Med. Jour.," Oct. 11, 1902. 
6 " Deut. Arch. f. klin. Med.," Bd. lviii. 



476 DISEASES OF THE CORD PROPER. 

The prognosis is not hopeful, but the course of the disease is 
usually very slow aud for a given family nearly the same in all the 
affected members. 



SCLEROSIS OF THE CORD DUE TO VEGETABLE INTOXICANTS- 
ERGOTISM, LATHYRISM, PELLAGRA, 

Ergotism.— Epidemics of ergotism have arisen in various localities 
of the Old World, usually in times of bad harvest, when the people 
were reduced to eating ergoted grain. Brain symptoms in the form of 
mania are often associated, and epileptoid attacks are common. The 
disease respects neither age nor sex, and sometimes animals present sim- 
ilar cord symptoms. These, in man, consist of paresthesias, lightning 
pains, girdle sensations, analgesia, static instability, and an ataxic gait 
with obliteration of the patellar reflexes. Neither optic atrophy nor 
pupillary stasis occurs. In all recent autopsies a sclerosis confined to 
the posterior columns, and conforming closely to the changes in tabes, 
has been found. In many instances the symptoms develop after the 
poisonous food has been discontinued for some months. The tendency 
of the disease is toward recovery by progressive amelioration during 
several years. In some instances even the knee-jerk is restored. The 
mortality, however, in acute cases, is rather great. (For fuller particu- 
lars the reader is referred to the article of Tuczek, " Archiv f. Psy- 
chiatric/' Bd. xiii, S. 99.) 

Lathyrism. 1 — Epidemics of this disease in Europe, Africa, and Asia 
have been noted for centuries. The cases are marked by rigidity of the 
lower extremities coming on within a few days, and paraplegic symp- 
toms, with weakness of the bladder, generally ending in slow recov- 
ery. They coincide with famine conditions, when the people eke out 
their subsistence with the various vetches, such as Lathyrus sativus, or 
cicera, or clymenum. The morbific constituent appears to be an alkaloid 
not destroyed by ordinary cooking. The symptoms come on gradually 
or sometimes rather abruptly, and a spasmodic paraplegia is developed, 
producing the paraplegic state, so far as motion and locomotion is con- 
cerned. Sensation is not materially disturbed, though paresthesias and 
some blunting of cutaneous sensation are usual. Mental symptoms and 
cerebral features, including involvement of cranial nerves, seem to be 
lacking. The exact lesion is not known, but the symptoms all point to 
disturbance in the lateral tracts, or, perhaps, to a posterolateral sclerosis 
with preponderating spasticity. Often such cases suggest a focal lesion 
of the cord, but the absence of serious sensory disturbance and the com- 
plete recovery that, as a rule, ensues are not consistent with such a point 
of view. 

Pellagra, from two Italian words meaning rough skin, is also known 
as pellarella, Alpine scurvy, Asturian leprosy, dermatagra, etc. 
Formerly it was mainly of European interest, being encountered prin- 
cipally in southern Europe, especially in northern Italy, and, to some 
extent, in northern Africa. It has been observed in Mexico, South 
America, and the West Indies. Although cases were reported in this 
1 Brunelli, "Trans. Seventh Internat. Cong.," vol. ii, p. 45. 



DISEASES OF THE WHITE MATTER OF THE CORD 477 

country by Gray, of Utica, N. Y., in 1864, only since 1907 has its 
wide distribution in the United States been recognized. Lavinder 1 es- 
timated that there were 1500 cases in the southern States between 1906 
and 1909. Several hundred cases were found in Illinois institutions for 
the insane in 1909, and scattered cases have been reported in many 
States. Pellagra may be defined or described as a periodic and progres- 
sive, non-contagious, non-inheritable disease, of insidious course, charac- 
terized by a peculiar, periodic eruption, and a series of symptoms involv- 
ing the nervous and digestive systems (Roberts). 

The exact etiology of the disease is still unknown. Lombroso, among 
the early Italian authors, so emphatically attributed it to maize, and 
particularly to bad or spoiled maize, that his views have always strongly 
colored the view. There is no positive evidence that Indian corn or its 
products plays any direct part in the causation of pellagra. That it 
may furnish a vehicle or pabulum for some organism is the most that 
can be said. Sambon, 2 in the latest authoritative study of the disease, 
denies the corn etiology altogether, and calls attention to the well-defined 
topographical limitation of pellagra in Italy to valleys and streams in- 
fested by a certain fly (simidium), which serves to explain the seasonal 
variations of the disease. Roberts 3 finds similar conditions to obtain in 
the State of Georgia, but the particular parasite is not yet in evidence. 
Conditions of impoverishment and exposure to the sun are such common 
factors as to be almost essential. The disease has a distinct relation to 
the summer season, and shows a strong tendency to recurrent annual 
attacks. Males and females are commonly said to be equally affected, 
but R. M. Griimur, 4 in a survey of twenty-five counties in Kentucky, 
South Carolina, and Georgia, embracing 1426 cases, found females more 
than twice the number of males, and whites much outnumbered the 
blacks. 

The symptoms of pellagra are of four orders, mental, cutaneous, intes- 
tinal, and nervous. Bianchi says that in Italy the disease appears in 
the spring, but more commonly in May and June, with general weari- 
ness and depression. Relapses occur at the same annual periods. Pains, 
paresthesias, vertigos, and malaise are soon associated with a dark 
erythema of symmetrical distribution on the portions of the body ex- 
posed to the sun — the neck, hands, and feet. It is sharply demarcated 
from the adjacent healthy skin, and its outline is dependent upon the 
protection afforded by clothing ; even rings, wristbands, and similar 
articles protect the underlying parts. When the erythema subsides, the 
skin remains harsh, thickened, wrinkled, and very much changed. 
Itching is pronounced. Blebs and bullae sometimes appear, a moist 
eczematous appearance is more common, and small scales form and fall 
rapidly. A general dyscrasia develops ; there are stomatitis, lack of appe- 
tite, gastric and abdominal pains, and persistent diarrhea. With advanc- 
ing prostration, dejection and melancholia appear. Paresthesias, cramps, 
ataxia, increased reflexes, and motor weakness are observed in a majority 
of cases. In a lesser number there are excitability and maniacal phases, 

1 "Pub. Health Report," 1909. 2 "Jour, of Tropical Med.," London, 1910. 

3 "Jour. A. M. A.," June 10, 1911. 4 "Pub. Health Report," March, 1913. 



478 DISEASES OF THE CORD PROPER. 

and in a few some of the mental and physical peculiarities of general 
paresis, such as expansiveness, egotism, excitability, with ataxia and 
increased deep reflexes. 

The American cases present some variations from the foreign types 
in that the erythema is usually not presented until the second year, and 
shows a greater intensity. Cord symptoms are less pronounced, and 
cord changes are less frequently mentioned in the autopsical records. 

The cord-lesions l that are found consist of a leptomeningitis, often 
with much thickening, and even with the formation of osseous plaques. 
In the cord itself the anterior cornual cells are frequently atrophied and 
pigmented. There is commonly a posterolateral sclerosis. This affects 
the columns of Goll and Burdach, mainly in the upper cord-levels, but 
spares the root-zone of the postero-external column. The crossed 
pyramidal tract, especially the lower portion, is also sharply sclerosed, 
the direct cerebellar tract usually escaping. 

The spinal symptoms correspond. Ataxia is most marked in the 
upper extremities ; spasticity is pronounced in the lower limbs. The 




Fig. 203, a.— Pellagrous erythema of the hands with ereat thickening of the skin (from the Bulle- 
tin of the Illinois State Board of Health, August, 1909). 

iridian reflexes are spared, and cutaneous sensibility is not much affected. 
Strangely, in spite of the usual changes in the anterior cornual cells, 
muscular atrophy is insignificant. The disease, clinically and anatomic- 
ally, sometimes presents much resemblance to paretic dementia. 

The course of the disease varies to such a degree that acute and 
chronic cases are everywhere encountered, the first frequently termi- 
nating fatally in a few months, the latter extending over many years 
with annual recrudescence. The tendency is to chronic insanity, espe- 
ciallv melancholia and terminal dementia, with a marasmic fatal exit, 
although recoveries are not uncommon. 

The treatment at present lacks any definite guidance. Arsenic, 
serums, dietetics, etc., have thus far equally failed. 
1 Tuczek, " Monagraphie sur la Pellagre," 1893. 






PAET VI. 

DISEASES OF THE GENERAL NERVOUS SYSTEM 
WITH KNOWN ANATOMICAL BASIS. 



Among the various diseases that have already been described, several 
have presented symptoms referable to the various portions of the entire 
nervous apparatus and properly belong to this section. Thus, in multiple 
neuritis all nervous levels may be invaded. Cerebral, spinal, and nerve- 
trunk lesions are all encountered. The same is true of cerebrospinal 
meningitis, tabes, paretic dementia, bulbospinal muscular atrophy, ergotism, 
lathyrism, pellagra, and polioencephalonu/etitis ; but for purposes of com- 
parison as well as contrast it was thought most expedient to take them 
up in the order chosen, being guided by the preponderance of nerve- 
trunk or spinal-cord features in each instance. To those named we here 
add multiple insular sclerosis and syphilis of the nervous system. AVith 
some of the syphilitic lesions we are already acquainted. 



CHAPTER I. 
MULTIPLE CEREBROSPINAL SCLEROSIS. 

Multiple cerebrospinal sclerosis — multiple sclerosis, insular sclerosis, 
sclerose en plaques, or disseminated sclerosis — is a disease secondary 
usually to some intoxication or infection often of a mixed sort. It is 
marked by numerous islets or plaques of sclerosis irregularly distributed 
in the brain, cord, and cranial nerves. These are related to the blood- 
supply of the part and probably primarily vascular. 

Etiology. — This disease is not very common. For instance, 
UhthofT in six or seven years could only gather about 100 cases 
from all the hospitals and clinics of Berlin. It affects both sexes 
indifferently and presents a large preponderance of cases between the 
ages of twenty and thirty years. Marie asserts its absolute rarity after 
forty, but cases do occur. Children are sometimes affected and it 
may even be congenital. Considerable stress was formerly laid upon 
heredity, but this element is chiefly manifest in a neuropathic tendency. 
Erb, Oppenheim, and Duchenne have cited examples of direct succes- 

479 



480 



DISEASES OF THE GENERAL NERVOUS SYSTEM. 



sion, and it has, in a small number of instances, affected several children 
of the same family. Hervouet has even seen nine cases in one gen- 
eration. Overwork, cold, traumatism, and various excesses have been 
accused as causative. Such relation is subject to doubt, though all 
these influences are capable of aggravating the disease when once estab- 
lished and of precipitating additional manifestations of its activity. 
Hoffman, 1 for instance, in a study of 100 cases, attributed the cause to 
trauma in 13, but in one-half of the cases no alleged cause could be 
mentioned. The most important etiological factors are the infections. 
Typhoid, pneumonia, malaria, measles, scarlet fever, small-pox, diph- 
theria, whooping-cough, erysipelas, dysentery, cholera, influenza, and 
the puerperium have been followed by the development of the symp- 




l 




Fig. 204. 



-Lesions of insular sclerosis in the 
brain (Charcot). 



Fig. 205. — Lesions of the insular sclerosis 
in the pons and medulla (Charcot). 



toms of multiple sclerosis within a few weeks or months. 2 Oppen- 
heim 3 found that in eleven out of twenty-eight cases treated by him 
the patients had long been exposed to the influence of lead, copper, 
zinc, etc., and emphasizes the significance of occupations attended by 
such intoxications. Charcot, in one of his later lectures, reported a 
case consecutive to cerebral rheumatism. Infection may explain some 
of the family groups of multiple sclerosis and Oppenheinr's observation 
of the disease in a mother and child. From the numerous and often 
^uixed infections noted, it seems unlikely that we have to deal with a 
specific organism. It is also a debated question whether the morbific 
microbes act through their elaborated poisons or by embolic colonization. 
It is, however, quite definitely settled that the irritative influence 
reaches the central nervous organs through the blood-channels and there 
sets up the localized sclerotic processes. Serodiagnosis and spinal fluid 
examinations have indicated a syphilitic factor in a considerable num- 

5 "Deut. Zeit. f. Nervenheilk.," Dec, 1901. 2 Williamson, "Brain," 1896. 

3 "Berlin, klin. Wochens.," March, 1896. 



MULTIPLE CEREBROSPINAL SCLEROSIS. 



481 



ber of cases (Nonne). Early sclerotic patches ordi- 
narily show a centrally diseased blood-vessel, and 
thrombi have been found in several instances which 
Bibbert, 1 with Marie, is disposed to attribute to 
microbic emboli. 

Goldscheider 2 declares the process analogous to 
that of an acute myelitis originating through the vas- 
cular supply, while Schuster and Bielschowsky 3 con- 
sider the change as primarily interstitial. 

Morbid Anatomy. — Ilacroscopically the men- 
inges retain their normal appearance. The pia 
mater is translucent and frequently the sclerotic 
patches on the cerebral and cord surfaces can be 
seen through it. These present various sizes and 
shapes and are usually grayish or pinkish gray in 
color. In some cases they may only appear after 
undergoing the action of bichromate and other hard- 
ening solutions. In distribution they recognize no 
law. Sometimes they are most frequent on the sur- 
face ; sometimes they are confined to the interior of 
the cord and brain. In a general way they seem to 
prefer the white substance to the gray matter. They 
are found from the cerebral convolutions to the filum 
terminale and in variable numbers from a few to 
several hundred. Their dimensions are those of a 
millet-seed to a walnut or larger, and they are often 
of irregular, but almost invariably of definite, outline. 
They may invade the cranial nerves, especially the 
optic, and the spinal roots are not exempt. On sec- 
tion, they present a retracted appearance if old, a 
salient aspect if recent. Both sorts may be found in 
the same case. 

Microscopically the definite outline of the plaques 
is still maintained, and they are sharply distinguished 
from the surrounding normal tissue. The myelin has 
disappeared from the nerve-fibers which pass through 
them, but the axis-cylinders usually persist and some- 
times are enlarged. In recent plaques there is an 
abundance of granular bodies throughout the islet, 
but in older lesions they are confined to the peri- 
phery of the plaque. Through and everywhere in 
the plaque is a proliferation of the neuroglia, at once 
the evidence and the result of the irritant cause of 
the lesion. Observers are agreed that secondary 
degenerations do not, as a rule, follow the develop- 
ment of these sclerotic patches. Deprived of their 
myelin covering, insulation is probably impaired in 
the nerve-fibers, and to this fact some writers attribute in part the trem- 

1 Virchow's " Archiv," 1895. 2 " Zeit. f. klin. Med.," Bd. xxx. 

3 "Neurolog. Centralbl.," 1897. 
31 



Fig. 206.— Distribu- 
tion of lesions of multi- 
ple sclerosis in the cord. 
Sections taken at various 
levels throughout its en- 
tire length (Charcot). 



482 DISEASES OF THE GENERAL NERVOUS SYSTEM. 

bling and other motor disturbances commonly presented. Occasionally 
myelinated fibers are found in old patches, and it has been suggested 
that they may be due to a regenerative process. These particularly occur 
in the pyramidal tracts and in Goll's columns. Popoff insisted that the 
alleged neuroglial hyperplasia does not exist, but regards this appearance 
as due to degeneration products of the myelin and axis-cylinders. Red- 
lich, 1 however, in a later study, insists fully upon the glial increase 
in ali cases. The nerve-cells embraced in the plaques are diminished 
in size, often pigmented, and their processes are atrophic or may have 
disappeared. 

In the optic nerve there is the same interstitial increase without division 
of axis-cylinders, and, according to Uhthoff, papillitis and atrophy of the 
disc only occur when the plaque is situated immediately behind the globe. 

The vessels in the plaques show decided changes. The coats are 
thickened, especially the external tunic, so that in section they remain 
open and dilated. The perivascular sheaths are also dilated and at 
times obliterated. In other instances thrombotic occlusion of the ves- 
sels has been observed. One vessel particularly altered is usually 
found near the center of each small sclerotic patch, and the sclerosis 
is most intense at and about this point. The appearance indicates that 
an early embolism or thrombosis sets up vascular lesions extending to the 
perivascular spaces, and entails irritative sclerosis of the adjacent neuroglia. 

A certain number of cases must be kept in mind where the early 
changes are due to diffuse myelitis or cerebritis, or both, and in wdiich 
secondary degenerations and numerous focalized softenings give rise to 
a similar clinical picture. 

Symptoms. — Wide-spread as are the lesions and haphazard as is 
their location in multiple sclerosis, the clinical symptom group of the 
disease is tolerably uniform and ordinarily easily recognized. 

The motor features constitute the most important group of symp- 
toms in multiple sclerosis. The gait is usually disturbed at an early 
period of the disease. Sometimes it is clearly and purely spastic, identi- 
cally the same as that presented in the paraplegic state : legs rigid, knees 
adducted, toes turned in and dragging along the ground ; clonus 
showing in the trembling, shaking legs, which are pulled up and 
advanced by swaying movements of the body and pelvis ; all re- 
flexes exaggerated. To this is usually added more or less uncer- 
tainty of equilibrium, and we have a combination of cerebellar stagger- 
ing and spastic rigidity which has been called the cerebellospasmodic 
gait, and is the one most frequently encountered. In exceptional cases 
the gait is purely cerebellar in quality, without any rigidity, and with 
diminished or normal reflexes. There is commonly more or less muscular 
weakness, which may reach a paraplegic degree and defeat all attempts at 
walking. One leg is often much more affected than the other, and this 
may even alternate from side to side at different periods of the disease. 
In exceptional instances the lower extremities are not affected. Exag- 
gerated reflexes are the rule, and the Babinski is a most valuable sign 
in many cases that show no other indication of organic disease. 

A considerable proportion of cases present apoplectiform attacks, fol- 
1 " Neurolog. Centralbl.," 1896, p. 562. 



MULTIPLE CEREBROSPINAL SCLEROSIS. 



483 



lowed by transitory paralysis at some period of the disease. In rare 
instances such an apoplectiform attack is the initial manifestation of the 
disease. 1 Sometimes both limbs and the face on the same side are 
involved ; sometimes we have a crossed paralysis ; sometimes the face 
escapes, and sometimes the palsy is paraplegic in distribution. 

The upper limbs present not only the spastic weakness already 
noted in the lower extremities, but here is developed to its highest de- 
gree the so-called intention tremor, which is characteristic of the dis- 
ease. While at rest the hands, trunk, and head are perfectly quiet ; but 
once the patient attempts to reach any article, especially if the movement 
be somewhat extensive and requires precision, the entire member be- 
comes animated with a coarse trembling which augments in amplitude 
as the movement continues. Finally the object is seized with con- 
siderable rudeness. The moment the arm is again placed at rest, and 
supported so that no muscular effort is expended, the tremor at once 




/ 





Ov^Vyv/Vy 



Fig. 207. — Handwriting in two cases of multiple sclerosis, showing irregular intention tremor. 

ceases. This tremor shows clearly in the handwriting of these patients, 
and writing may finally become impossible. Unlike the trembling of 
paralysis agitans, which is most pronounced in the lingers and while at 
rest, the intention tremor of multiple sclerosis usually arises at the 
roots of the extremities, and they are moved in their entirety from the 
shoulder- or hip-joints. This accounts for the icide range of the tremor 
excursions, and perhaps for their slow rate, which usually is between 
five and eight to the second. The lower extremities may also present 
this intention tremor to some degree, and it frequently shows in the 
trunk and head of the patient if without back-support or head-rest. 
The movements of the head are usually anteroposterior in direction, but 
may also be somewhat lateral and then tend to produce circumduction 
of the head upon the shoulders. Frequently the tremor is much more 
marked on one side than on the other, and rarely it is unilateral. 

One of the ordinary tests of this tremor is to direct the patient to 
take a drink from a tumbler of water. In marked cases the tremor 
appears directly the hand starts toward the glass. This is reached in a 
fairly direct line, grasped suddenly, and with increasing oscillations 
carried toward the lips, which are protruded to meet it, with the head 
and body advanced and shaking. The motions become more and more 
vigorous, and finally the glass is rattled or dashed against the teeth, and 
the water not already spilled may drench the patient's face and clothing. 
1 Boulogne, '"Rev. de Med," May, 1893. 



484 DISEASES OF THE GENERAL NERVOUS SYSTEM. 

The little remaining is obtained by steadying one hand with the other, 
and firmly holding the glass with the mouth. This tremor is increased 
by embarrassing emotions, and is somewhat proportionate to the extent 
and duration of the movement attempted. 

Sensory features in multiple sclerosis, in a general fashion, may 
be said to be insignificant, so far as general sensibility is concerned. 
Occasionally a patient complains of anomalous sensations of heat or 
cold, formication, fullness in the limbs, and sometimes of pains which 
may even be lightning-like in character or of the girdling form. Ac- 
cording to Freund, the slight objective sensory changes sometimes 
encountered are confined to the fingers and toes mainly, and to the 
distal portions of the limbs. They consist of disturbance of touch, of 
hyperalgesia and analgesia, and insignificant modifications of thermic 
sensibility. They are often transient and changeable. F. von Gebhardt 1 
claims that in advanced cases certain areas present permanently dis- 
ordered sensation. Hemianesthesia and other hysterical distributions 
of anesthesia sometimes complicate multiple sclerosis, as the diseases 
may be, and often are, associated. 

Hearing, taste, and smell are singly disordered in rare cases of multi- 
ple sclerosis, usually in the direction of deficit, and may be completely lost. 

Disturbance of sight, on the other hand, is frequent, often very 
marked, and of great diagnostic value. The ocular apparatus may be 
affected in any portion of its neuromuscular make-up. Nystagmus, 
usually consisting of lateral movements, is presented by over half the 
cases, perhaps in seventy per cent. True nystagmus, in which the eyes 
constantly oscillate, occurs about once out of five such cases, the other 
four presenting nystagmiform movements only on occasion, particularly 
when the eyes are forcibly deviated to the right or left. It should 
be sought by directing the patient's line of sight throughout the 
entire lateral and vertical range of ocular movement. In seventeen per 
cent, of cases Uhthoff found paretic conditions of the extrinsic eye-mus- 
cles. These, like the hemiplegic features, are usually transient. They 
may constitute a complete external ophthalmoplegia, or be confined to any 
of the motor oculi nerves, or to portions of the third cranial pair. They 
are, as a rule, bilateral and affect the associated movements, showing their 
nuclear nature. The nystagmus is of a similar nature, and probably 
due to the disturbed muscular balance. 

The pupils may show miosis, inequality, and diminished reflexes to 
both light and accommodation, but the Robertson pupil is practically 
unknown, and miosis is usually associated with an exaggeration of the 
light reflex. 

The optic nerve is very frequently affected and vision is often modi- 
fied. The papilla may show optic neuritis or atrophy, but the atrophy 
is very seldom extreme, and the disc usually retains some color in a part 
of its expanse. Some papillary modification is found in over one-half 
of all cases, and some cases showing no changes in the nerve-head still 
present visual defects. Vision may be slowly or rapidly reduced and 
blindness may follow, but the amblyopia is ordinarily transitory, and a 
considerable degree of sight is frequently restored. Central scotomata, 
1 " Dent. Arch. f. klin. Med.," Bd. lxviii, No. 1 u. 2. 



MULTIPLE CEREBROSPINAL SCLEROSIS. 485 

irregular or regular retraction of the field, dyschromatopsia, particularly 
for red and green, may be variously combined in the field, and in these 
respects the ocular disturbances are rarely symmetrical and may be en- 
tirely unilateral. They may be of insidious or rapid development and 
may be early or late manifestations of the disease. They bear a rough 
relation to the intensity of other symptoms and often increase corre- 
spondingly with them. 

Visceral disturbances are insignificant in insular sclerosis. Rectal 
and vesical incontinence or retention, gastric crises, and other similar 
manifestations of organic disease of the cord are sometimes encountered, 
but are not severe in degree or constant in appearance. 

Trophic disturbances are unusual. Loss of nails, gluteal decubitus, 
and localized wasting of muscles, particularly of the interosseous mus- 
cles of the hand, have been met with. 

Bulbar Symptoms. — Difficulty in swallowing and in mastication, 
trembling of the tongue, inability to protrude it, glycosuria, and 
polyuria are occasionally encountered, and, with the other bulbar symp- 
toms already noted, point to the location of sclerotic patches in that region. 

Cerebral Features. — Among the most characteristic symptoms of 
multiple sclerosis is the speech defect This is very commonly present 
and consists of a slow, monotonous, scanning pronunciation that slights 
no syllable and ends abruptly, spasmodically, explosively with the last. 
It sometimes causes elision of the final sounds or every syllable may be 
slurred. There is a distinct effort to articulate each sound with rests 
between. This staccato speech, in marked cases, is well marked, but 
in some instances it may lack some of its features or entirely default. 
Its mechanism is of difficult explanation, but is, at least in some cases, 
attributable to faulty action in the articulative muscles. 

Vertigo is sometimes present and may disturb the patient at rest or in 
walking. In some cases the nystagmus causes objects to dance before 
the eyes ; in others, with ocular-muscle paresis, there is diplopia, both 
of which may cause vertigo. In rare instances the vertigo presents 
Meniere's type. The apoplectiform and epileptiform attacks that have 
been already incidentally mentioned, sjxismodic laughter and crying and 
slight mental enfeeblement, with indifference and dejection, indicate cerebral 
lesions. In rare cases an expansive, egotistic delirium of grandeur 
may appear closely resembling that of paretic dementia, and complete 
dementia may ensue. Hunt x insists that paretic dementia and multiple 
sclerosis are sometimes combined in the same subject. 

Hoffman, 2 in the 100 cases on which he based his study, found 
speech difficulties in 54, giddiness in 64, headache in 40, optic atrophy 
in 50, nystagmus in 56, intention tremor in 71, paresthesia in 66, and 
objectively disturbed sensation in 28. The sexes were about equally 
represented by 47 women, 53 men. 

Course and Forms. — The onset may occur abruptly by an apoplec- 
tiform attack, followed immediately by hemiplegic or paraplegic or 
monoplegic weakness, or these may suddenly appear without the con- 
vulsive attack. In other instances vertigo or visual disturbance sud- 
denly opens the program. More frequently the onset is gradual and 

1 "Am. Jour. Med. Sci.," Dec, 1903. 

2 "Deut. Arch. f. klin. Med.," Bd. lxviii, No. 1 u; 2. 



486 DISEASES OF THE GENERAL NERVOUS SYSTEM, 

the course progressive. Difficulty in walking or in speaking or the 
trembling is first noticed and gradually increases, leading in the other 
prominent features of the malady. Sometimes the initial feature con- 
sists of attacks of pain of a stabbing, lancinating variety. The advance 
of the disease may be chronically progressive, or it may show exacer- 
bations or remissions, and continue finally to advance. Sometimes the 
amelioration is permanent and recovery is possible. In progressive 
cases death may result from intercurrent maladies, from an apoplecti- 
form attack, from bulbar accidents, or from the exhaustion of terminal 
dementia. 

The duration of the disease, like its anatomical basis and its symp- 
toms, is very variable. It may reach full development within a few 
months or a year, rarely almost at a bound. It may terminate in a 
year, last twenty, or recede completely at any time. Marburg, Blumenau, 
von Koch, and others have reported acute cases reaching a fatal termin- 
ation in about three months. 1 

In some instances only one or a few of the most notable symptoms 
of the disease ever develop. These cases constitute the formes frustes 
of Charcot. Thus the trembling, or the speech defect, or the gait with 
or without nystagmus, or bulbar symptoms and amyotrophy may pre- 
dominate, while other symptoms are only very slightly developed. 

Diagnosis. — In a well-developed case the diagnosis may be made. 
The intention tremor, cerebellospasmodic gait, spastic weakness, nystag- 
mus, and syllabic speech make a positive picture. The differentiation 
from family ataxia may, however, present great difficulty when several 
members of the same family are affected with multiple sclerosis. Fried- 
reich's disease is marked by flaccidity and abolished knee-jerks, the 
motor difficulty is purely ataxic and never spasmodic, and optic-nerve 
symptoms are practically always absent. In the heredocerebellar type 
of family ataxia there are increased reflexes and often optic atrophy, but 
a long family succession of cases rarely fails us, and the motor difficulty 
here again is devoid of spasticity and is purely ataxic. In neither type 
do we find the well-developed syllabic speech nor the intention tremor, 
though the speech is modified and ataxic and there are choreic move- 
ments which might at first mislead. Cases clinically mistaken for amy- 
otrophic lateral sclerosis have been recently reported by Probst and 
Brauer, one for transverse myelitis by Siemerling, and one for a Brown- 
Sequard paralysis by Jeremias. 

Hysteria is capable not only of mimicking every objective symptom 
Of insular sclerosis, but sometimes is associated with it in the same 
patient. It should never be out of mind in making the diagnosis, and 
the stigmata of the neurosis should be faithfully sought in every instance. 
Cases showing hysterical signs and the symptoms of multiple sclerosis, 
according to Buzzard, 2 should be looked upon as probably organic if the 
tendon reflexes are exaggerated and, at the same time, the plantar reflex 
is abolished. This observer has noted optic atrophy in one-half of his 
cases of insular sclerosis, and found Babinskr's toe-sign in all in which 
it has been sought. 

1 " Wiener klin. Rundschau," 1908, No. 34 ; " ftorsakoffsch.es Jour.," 1908, No. 5. 

2 "Brit. Med. Jour.," May 6, 1899. 



SYPHILIS OF THE NERVOUS SYSTEM. 487 

111 the partial cases, mainly marked by one of the prominent char- 
acteristics of multiple sclerosis, the diagnosis is decidedly difficult. In 
every such instance all the features of insular sclerosis should be sought, 
and some of them, if only partially developed, will be found to fix the 
diagnosis, or the presence of signs of other diseases will guide. When 
trembling predominates, we must exclude paralysis agitans, metallic 
intoxications, chorea, and hysteria. When the speech defect is most 
prominent, we must think of paretic dementia and the family ataxias. 
In cases showing a predominance of cerebellar ataxia intracranial tumors 
and the family ataxias must be excluded. When the gait is purely 
spastic, we must exclude transverse myelitis and the combined scleroses 
of the cord. 

Prognosis. — While the outlook in a case of multiple sclerosis is 
always grave, the tendency to remissions and the occasional complete 
recession of the disease make it distinctly more hopeful than in the 
destructive sclerotic lesions of tabes and cross-myelitis. It is impossible 
in a given case to forecast its probable course so long as it is progress- 
ing. Apoplectiform seizures followed by paralytic features and aggra- 
vation of all the symptoms may occur at any moment ; but when the 
disease has shown remission and improvement we are justified in hop- 
ing, with due reservation, for better things. 

Treatment. — In every case the nature of the origin of the malady 
will guide therapeutics. If the disease is to be considered as mainly 
due to infections and to the continuous activity of microbic life, which 
from time to time leads to new plaques or increases old foci, bactericidal 
preparations are indicated — quinin in malaria ; mercury, iron, arsenic, 
and salicyl preparations in other septic conditions. Generally speaking, 
an antisepticemic regime is in order. This may only be valuable when 
the general resistive powers of the economy are increased by the best 
hygienic and general health measures. The future may furnish some 
organic antitoxin more powerful than our present medicaments. 



CHAPTER II. 
SYPHILIS OF THE NERVOUS SYSTEM. 

The syphilitic lesions of the nervous system, especially of the cen- 
tral apparatus, are of extreme frequency and of almost infinite variety. 
In this section little more can be attempted than an enumeration of 
them, with special reference to clinical peculiarities and the most effica- 
cious mode of treatment. 

Syphilitic nervous disease may be divided into (1) those due to 
the active ravages of the treponema pallida and (2) those which follow 
the infection and are not marked by neoplastic products. The one is 
specific, the other parasyphilitic. The first is parasitic, the second toxic 
or chemical. Such a view of luetic lesions and consequences gives us 
the best working basis at the present time. The so-called parasyphilitic 
diseases may, however, owe their progressive characters to the constant 
though slight action of persistent parasitic activity. The almost invari- 
able positive Wassermann finding, a lymphocytosis of the spinal fluid, 



488 



DISEASES OF THE GENERAL NERVOUS SYSTEM. 



and the active globulin reaction of Noguchi in this fluid support the 
idea of a persistent specific spirillosis. Noguchi 1 has been able to dem- 
onstrate the spirochete of syphilis in the cord lesions of 1 case of 
tabes out of 12 examined. The distinction, therefore, between ac- 
tive and parasyphilitic lesions is one of time rather than of kind. 
Syphilis is capable of transmission to offspring in either form, and we 
have some hereditary syphilitic diseases of the general nervous system 
marked by the ordinary gummatous processes, and others of the de- 
generative order. Again, both the syphilitic and parasyphilitic lesions 
may be present in the same individual at the same time or at different 
periods. The following tabulation may serve to systematize the subject: 



g 



< 

M 
H 
525 

w 02 



Active specific 
lesions 



Cerebrospinal 

syphilis, acquired 

and hereditary 

(early and tardy) 



_ Syphilis of nerves. 



Parasyphilitic 
diseases 



Acquired 



Hereditary 



^ f Meningitis 

£ J Cerebritis 

g 1 Arteritis 

<j [ Neuritis 

9 Meningoniyelitis 

■9 -J Myelitis 

m Spinal paraplegias 

Tabes 

Paretic dementia 

Ataxic paraplegia 



Mania 

Melancholia 

Pseudoparesis 



Optic atrophy 
Nei 



Neurasthenia 
Hysteria 
Epilepsy 
Neuralgia 

Juvenile tabes and paresis 
Infantilism 
Hydrocephalus 
Cerebral or spinal agenesis 



Specific lesions of the general nervous system, like specific lesions 
elsewhere, originate in the connective tissue or blood-vessels and sec- 
ondarily affect the parenchyma, disturbing function first and finally 
destroying the essential cells and fibers of the part. Rarely they arise in 
bony structures and thence invade the adjoining nervous apparatus or act 
upon it by pressure. Their peculiarity is in the gummy plastic exudate 
with its formative tendency and the presence of the parasite. It is 
essentially a neoplastic process, which may vary from an appearance of 
simple inflammation to the accumulation of sizeable tumors. In early 
stages there is often a marked tendency to regressions and recidives. 
Old lesions, if of considerable size, may caseate within and cicatrize 
upon the surface by fibrous organization, and fibroid changes may alone 
remain to indicate the preexisting gummy condition. 

Acquired syphilis affects the central nervous system by specific 
lesions in a very considerable proportion of all luetic cases. Hjelmann, 
leaving out of the question both tabes and paretic dementia, states that 
from 11 to 2f per cent, of all cases of syphilis develop cerebrospinal 
lesions, and that of those presenting the tertiary features of the infec- 
tion, twelve per cent, show invasion of the cerebrospinal axis. Four- 
nier puts this latter percentage at twenty-one. In the great majority 
of cases the syphilitic process is wide-spread and somewhat haphazard 
in its location. Very rarely do cases of spinal syphilis lack evidences 
of cerebral involvement at some period, but cerebral syphilis, on the 
1 "Munch, med. Woch.," April, 1913. 



SYPHILIS OF THE NERVOUS SYSTEM. 



489 



contrary, is sometimes devoid of spinal complications. We may, for 
descriptive purposes, divide these cases of acquired active syphilitic 
lesions into the cerebral and the spinal. Their common association 
should never be forgotten. 

CEREBRAL SYPHILIS. 

Syphilitic cerebral meningitis is perhaps the most frequent form 
of cerebral syphilis, and usually, to some extent, complicates all other 
varieties of encephalic lues. The favorite location is the basilar area, 
especially the interpeduncular space, from which it frequently extends 
upward on to the convexity of the parietal, and particularly of the frontal, 
lobes. So commonly is the base affected that, speaking clinically and 
according to Charcot, it may never be considered exempt, even when 
the symptoms point to the convexity alone. The distribution recalls 
that of tuberculosis. A gelatinous transparent substance infiltrates the 
soft meninges about the circle of Willis and the optic chiasm. It is 
composed of small, round, embryonic cells, and is very vascular and 
viscoid. Caseation and sclerotic degeneration mark the lesion later. 
The adjoining or enveloped nerves and 
vessels may be injured. JNeuritic atrophy on 
the one hand and obliterating arteritis on 
the other are thus set up. Extension of the 
process to the nerve-sheaths and interstitial 
structure accounts for the very frequent 
symptoms on the part of the cranial nerves 
in cerebral syphilis. 

In the field of syphilitic meningitis 
gummy masses, or gummata, are usually 
encountered. They vary in size from mili- 
ary bodies to tumors as large as filberts, 
which may be solitary, few, or many in 
number. Their favorite location is at the 
base or on the convexity, especially on the 
frontal lobes, but no portion of the brain is 
exempt. Sometimes they form on the sur- 
face or in the thickness of the dura mater, 
or deeply within the brain, on some septal 
infolding or penetrating blood-vessel. They 
comport themselves as do brain-tumors generally, and give rise to similar 
localizing signs and symptoms. Sclerous or fibrous degeneration marks 
the later stages of all these specific neoplastic lesions, and gives rise to 
what is sometimes called sclerous syphilitic meningitis. 

Syphilitic cerebritis may exist as a direct extension from a specific 
meningitis or gumma, or may occur more or less independently. It may 
present itself as a diffuse, gummatous encephalitis, or as localized en- 
cephalic gummata which tend to caseate, or it may appear in circum- 
scribed patches or plaques, especially in the pontine and peduncular 
surfaces, which may end in sclerous patches. Every syphilitic process 
in the brain entails a surrounding zone of cerebral softening or cerebritis. 

Syphilitic Cerebral Arteritis. — Syphilitic endarteritis in the brain 




Fig. 208.— Ocular palsy in a case 
of brain syphilis in which at one 
time there was a crossed hemiplegia, 
right face and left extremities. The 
right eye overacts, turning upward 
and outward in looking to the right. 



490 DISEASES OF THE GENERAL XERVOUS SYSTEM. 

is a comparatively common accident. It may result in the oblitera- 
tion of the large basilar vessels secondarily to a gummatous menin- 
gitis, or it may develop as a primary focus of syphilitic activity. Its 
legitimate result is a localized ischemia, which, if complete, results in 
thrombotic brain-softening. Heubner insists upon its frequency in the 
basal ganglia. The middle cerebral arteries are frequently affected 
either in the numerous small branches of the Sylvian or by the complete 
obliteration of this motor-zone vessel. 

It is also established that cerebral hemorrhages may follow a specific 
arteritis. This rarely occurs within the brain-substance, but more often 
takes place in the large and comparatively unsupported basilar vessels, 
resulting in a foudroyant apoplectic stroke almost immediately fatal. 

Syphilitic Lesions of the Cranial Nerves. — Owing to their 
exposed position at the base, where specific cerebral invasion is most 
common, the cranial nerves are very commonly implicated. The relative 
frequency with which they are affected diminishes from the chiasm and 
optic nerves backward toward the bulb. The order is as follows : 
Optic nerves, motor oculi, abclucens, trifacial, facial, auditory, and only 
rarely the glossopharyngeal, vagus, and hypoglossus. 

The motor oculi, or third nerve, is affected in about forty per cent, 
of the cases, and shows a particular vulnerability on the part of the fibers 
supplying the levator of the upper lid. Hence the frequency and sig- 
nificance of ptosis. Inequalities of the pupil and pupillary stasis are of 
equal importance and frequency. A rigid pupil should always raise a 
suspicion of syphilis. It is to brain-syphilis what the Eobertson pupil 
is to tabes. Referable to the affection of the chiasm and optic nerves 
and tracts we find all forms of irregular and unequal contractions of the 
visual fields. Optic neuritis is very frequently present and atrophy 
may result. The trifacial may be involved in one or all its branches, 
causing disturbed sensibility sometimes, but more frequently neuralgic 
pains of corresponding distribution. Infrequently facial palsy is en- 
countered, and in rare cases this is associated with deafness on the 
same side. 

The amount of injury to a nerve varies within wide limits, but often 
presents the suggestive peculiarity of advance and recession, giving rise 
to temporary, fugaceous palsies and temporary sensory features, such as 
amblyopia, lasting a day or two. After several such attacks the dis- 
ability is likely to persist permanently and indicates a destructive change 
in the nerve, which commences as an interstitial infiltration and neuritis. 

The general symptoms of cerebral syphilis are modified by the 
particular lesions that are present. These, as a rule, are multiform, but 
with special prominence of certain features. One case attracts most 
attention by its eye symptoms, another by its neuralgic pains, another by 
its convulsive manifestations, another by its stupor or mania or paralysis. 

There is always, or nearly always, an initial period — a premonitory 
period — that it is o± the greatest importance to recognize. Then only 
does medication offer a fair chance of effecting a cure. Once passed, 
irreparable damage is done, and the best that can be hoped is to check 
further mischief and leave the brain and nerves scarred with cicatricial 
tissue. Brain-syphilis appears, ordinarily, during the secondary period, 



SYPHILIS OF THE NERVOUS SYSTEM. 491 

but may occur at any date after the first few months. Thus the first 
year shows the greatest number of cases, which diminish gradually, year 
by year, to the end of life. There is no period of exemption after infec- 
tion. Cases of brain-syphilis are encountered twenty, thirty, and forty 
years after the initial sore, and probably many syphilized individuals die 
from other causes and thereby escape luetic brain accidents. If ter- 
tiary manifestations appear, the likelihood of the occurrence of brain- 
syphilis is increased. It is important to know that a blow or jar to the 
skull may precipitate and focalize syphilis in the brain, and may greatly 
aggravate it when present. The same is true of mental shock and fright. 
The phenomena of the premonitory stage consist of headaches, disturb' 
ances of sleep, mental changes, and physical decline. 

The headache in its typical form is atrocious in severity, often cir- 
cumscribed, and deeply seated. It is frequently marked by local ten- 
derness on percussion and shows daily, usually nocturnal, exacerbations. 
The syphilitic headache may remit without apparent cause, or an ex- 
acerbation may be followed by a ptosis or an amblyopia, or it may ter- 
minate upon the appearance of a hemiplegia or other serious secondary 
brain-lesion. Usually the only sedative capable of controlling it is 
morphin, but it yields in a few days to either mercury or the iodids. 
While the headache is mainly vesperal or nocturnal, in some instances it 
is most severe in the morning and some trace of it usually lasts through- 
out the twenty-four hours. Commencing in a localized area, it may 
gradually invade the entire head, and frequently, if unchecked by proper 
treatment, lasts weeks and months. 

The sleep is modified in two ways. There is insomnia or sopor. 
The nocturnal headache in itself may destroy sleep at night, but in 
addition the patient often fails to sleep after the headache subsides. 
Insomnia often occurs early, before the headache has grown intense. 
Later, there is usually a tendency to stupor, and this also may appear 
early. The patient drops to sleep at any time during the day, at his 
meals, over his paper or desk. Aroused at night by the cephalalgia, he 
drops back into a heavy, stuporous sleep, and often requires vigorous 
rousing. In a somnolent way he may get up for any purpose and at once 
drop to sleep on returning to bed. The stupor may become continuous 
and reach a comatose depth. 

Mental changes ordinarily accompany the cephalalgia. The patient's 
wits are dulled. He is apathetic, disinclined for study, work, or social 
enjoyment. The memory is frequently impaired. He looks and acts 
and feels depressed and indifferent. His ideas come slowly and he may 
show irritability or become greatly depressed. 

The general health often fails. The appetite is commonly lost early, 
strength diminishes, flesh is lost, and the skin and mucous membranes 
grow pale and anemic. Often at this time vertigos, tingling in an ex- 
tremity, inequalities in the pupils, a drooping lid or some twitching of a 
limb indicate the impending storm and show its direction. 

Special Symptoms. — After the premonitory period or even from 
the first the disease shows one of three major tendencies, marked by 
the preponderance of meningitis, arterial accidents, or tumor formation, 
respectively. These may be and usually are variously combined. 



492 DISEASES OF THE GENERAL NERVOUS SYSTEM. 

The meningeal form is marked by extreme depression and torpor. 
The patient lies like one narcotized or stupefied with alcohol. At times 
he can be roused to answer in monosyllables, but promptly subsides into 
the lethargic state and may become unconscious and comatose for a few 
moments, for an hour, or for several days. When he talks it is in an 
uncertain and unreliable way. Frequently there is a little delirium. 
His headache alone seems to cause him trouble. Usually pupillary 
sluggishness and inequality are present, ptosis and squints are frequent, 
and diplopia sometimes admitted. There may be urinary incontinence 
or retention. Fever is ordinarily, but not invariably, absent and the 
physical functions are well carried on. Death rarely results from this 
form of cerebral syphilis, but, on the other hand, complete recovery is 
equally rare. Some trace in the way of mental apathy is likely to per- 
sist. In exceptional instances there is wild, maniacal delirium and 
motor excitement, an elevated temperature, and quickened pulse. 

The Arterial Form. — Cerebral syphilitic arteritis is usually accom- 




Fig. 209.— Brain showing basilar syphilitic meningitis, with generalized exudate and small cysts in the 
deeper furrows (Dr. W. A. Jones). 

paniecl by basilar specific meningitis and the premonitory headache. 
Cranial-nerve symptoms are also usually present. It gives rise to 
thrombus and cerebral softening, resulting in hemiplegia or monoplegia, 
or aphasia or other localized cortical disability. Usually this does not 
come on at once, but by slight premonitory strokes and numerous 
a warnings." Transitory plegias and aphasias are always suggestive 
of syphilis. When the motor cortex is involved, spasm or partial 
epilepsies are commonly induced. The rule applies here, as in gum- 
mata, that epileptic seizures after the age of thirty are generally due to 
syphilis, and that paralytic seizures in adults, before the age of forty, in 



SYPHILIS OF THE NERVOUS SYSTEM. 493 

the absence of cardiac and renal lesions, are almost invariably syphilitic. 
Another indication of syphilis is a multiplicity of lesions. A double 
hemiplegia or left hemiplegia with aphasia or pseudobulbar palsy from 
double-sided lesions, or cerebral hemiplegia and paraplegia from brain- 
and cord-lesions, in the same case, speak for syphilis. 

Hemorrhage, as already indicated, is usually from a large basal 
vessel and is promptly fatal. It is commonly secondary to aneurysmal 
degeneration and is a rare cause of death in syphilitics. Occasionally 
thrombosis, beginning in the circle of Willis, eventually reaches and 
obstructs the basilar artery, and death follows coma. 

The gummatous form of cerebral syphilis is usually marked by 
focal symptoms, and here all the rules of cerebral localization apply. 
As above indicated, the favorite location for gummata is at the base and 
upon the frontoparietal convexity, precisely the regions in which focal 
symptoms arise. These consist of cortical states of irritation and de- 
struction, — in other words, of limited epileptic attacks and cortical palsies, 
and of cranial-nerve lesions. Usually the focal signs and symptoms in 
gummatous cases are preceded by the premonitory phenomena. This 
might be expected, as the usual meningeal or cortical gumma is sec- 
ondary in point of time to a more or less diffuse specific meningitis. In 
rare cases the convulsion is the first manifestation of cerebral invasion. 
Generalized fits and epileptiform convulsions are not rare in diffuse 
cortical syphilis, and may be associated with the Jacksonian attacks, 
petit mal, momentary aphasias, sudden " thickening of the tongue," and 
similar evidence of circumscribed lesions. Syphilis also seems capable, 
according to Fournier, of producing a parasyphilitic epilepsy to which 
attention will be recalled. (For further details regarding cerebral gum- 
mata the reader is referred to the chapter on Cerebral Tumors, page 261.) 

Syphilitic Mental Diseases. — The mental disturbances of brain 
syphilis are those of organic brain disease, but in subjects strongly pre- 
disposed to insanity the syphilitic cachexia may induce ordinary forms 
of insanity. Morbid mental states due to the encephalic ravages of lues 
are most frequently of the depressed varieties grouped under the generic 
name of melancholia, with a decided tendency to dementia. Less fre- 
quently there is exaltation and delirium, which may be intense, and in 
both forms hallucinations are common. Signs of gross brain-lesions are 
rarely wanting. Cranial-nerve symptoms, localizing fits, monoplegic 
palsies, and speech defects point the way to diagnosis. 

In some instances symptoms arise that closely ape those of paretic 
dementia, and give rise to the term syphilitic pseudoparesis. The differ- 
ential diagnosis may, indeed, be impossible. The features suggesting 
active syphilitic disease, as contrasted with the degenerative changes 
of paresis, are a less steadily progressive course, less expansiveness, less 
amnesia, less speech difficulty, absence of the Robertson pupil, presence 
of cranial-nerve palsies and early monoplegias, and improvement under 
antisyphilitic treatment. Syphilophobia and hypochondriasis, arising 
from the knowledge or fear of being infected, have only an indirect 
relation to the disease. 

Diagnosis. — The diagnosis of encephalic syphilis, when there is a 



494 DISEASES OF THE GENERAL NERVOUS SYSTEM. 

plain history and marked evidences of previous infection, ordinarily 
presents no difficulties. In cases where such data are lacking, one of the 
nicest of diagnostic problems is furnished. Neeturnal headaches of the 
character described, epileptoid attacks occurring after the age of thirty, 
or apoplectic attacks appearing before the age of fifty, should at once, 
singly or in combination, raise the suspicion of syphilis. A history of 
any sort of a genital sore strengthens the case ; and if, in addition, the 
slightest secondary manifestation can be detected or recalled by intelligent 
cross-questioning, small doubt remains. It may be stated that the great 
majority of cases of syphilis of the nervous system present very slight 
secondaries, or these may have entirely escaped attention. Another indi- 
cation of syphilis in brain disease is a multiplicity of lesions. Cord and 
brain symptoms in the same patient are significant, as are double-sided 
brain-lesions or lesions of both base and convexity. The almost con- 
stant presence of basilar gummy meningitis, with its consequent cra- 
nial-nerve symptoms, among which are ptosis, pupillary abnormalities, 
and optic-nerve disturbances, often alone is sufficient to guide the diag- 
nosis. The mode of development counts for something. In brain-syph- 
ilis the onset is rarely sudden, but is, rather, by repeated advances, with 
remissions. Fugaceous palsies and fleeting sensory losses are the rule 
in syphilis. The phenomena of the premonitory phase can not be too 
strongly insisted upon. Sterility in male or female should be given a 
certain weight, and repeated miscarriages frequently incriminate the 
husband. 

Wassermann's positive reaction in the blood may be considered as 
strongly confirmatory of a clinical diagnosis when the other conditions 
which are capable of giving this reaction are or can be excluded. The 
spinal fluid in cerebrospinal syphilis, according to Nonne, presents the 
positive globulin reaction in every case: in from 90 to 95 per cent, of 
tabes and in from 95 to 100 per cent, of paresis. There is an increase 
of cells in the spinal fluid in at least 40 per cent, of early syphilis of the 
cerebrospinal area and in over 90 per cent, of the late or parasyphilitic 
conditions. The Wassermann reaction in the spinal fluid is positive 
in nearly every case if reliably made. These four reactions furnish 
positive evidence of the most substantial sort, but the clinical diagnosis 
is equally or more important. Finally, the therapeutic test stands for 
considerable. If, under adequate alterative dosage, the disease yields 
within a week, it sustains the diagnosis to some degree; but we must 
never forget that in other organic processes, even in sarcomatous 
tumors, the iodids may cause a notable remission in the symptoms. 

Prognosis. — The outlook is far from favorable, though it is too com- 
monly assumed to be so. It may be safely stated that less than one-half 
of the cases of brain-syphilis completely recover. Fournier, in 90 cases, 
reported 23 unrelieved, 13 improved, 14 died, and 30 recovered. Of 
those recovered, probably many presented recurrences later in life. In 
a general way we may expect to check the progress of active syphilitic 
processes excepting in rare cases of a malignant and unmanageable char- 
acter, where the human organism can not tolerate a medication intensive 
enough to permanently subdue the disease. The golden opportunity is 



SYPHILIS OF THE NERVOUS SYSTEM. 495 

in the prodromal stage. Lesions that have caused destruction of nervous 
tissue, such as results from thrombotic softening, secondary degeneration, 
hemorrhagic disintegration, and sclerotic strangulation, leave indelible 
and irremediable effects. In view also of the known ability of syphilis 
to lie latent and dormant for years, and its clinical remissive tendency, 
the wise physician will always maintain great reservation in even the 
most promising cases. Marked and prolonged stupor and decided mental 
disturbance make the expectation of complete restoration very slight. A 
patient who has once developed syphilis of the cerebrospinal apparatus 
is never safe and must maintain medical supervision, and under the 
guidance of blood and spinal fluid tests should undergo courses of treat- 
ment at intervals as long as life lasts. 

Treatment. — The treatment is the same as that in the spinal form, 
now to be considered, and will be detailed in that connection (page 498). 

SPINAL SYPHILIS. 

Nearly if not every case of spinal syphilis sooner or later presents 
evidences of cerebral invasion, and the diagnosis of syphilis of the cord 
often depends upon this association. It is proposed in this section to 
mainly emphasize the cord-lesions. 

Syphilis of the spinal cord and membranes is somewhat more 
precocious in its appearance than brain-syphilis, and most frequently 
appears from the third to the sixth month of the syphilitic history. It 
then diminishes in frequency during the rest of life. As within the 
skull, spinal syphilis is a disease of the meninges, nerve-roots, and 
blood-vessels. The cord-changes are invariably secondary and, in a 
sense, mechanical. It may involve any or all of the membranes as a 
specific meningitis, which sometimes is marked by gummatous thick- 
ening and tumor formation, but much less commonly than is the 
case within the skull. The nerve-roots and pial vessels are frequently 
involved in the specific meningitis, which may also extend to the periph- 
ery of the cord. Another group of conditions arises from impairment 
of the blood-vessels. Endarteritis, endophlebitis, and thrombosis may 
cause disturbance of the circulation in any part of the cord. They may 
cause softening and changes that are clinically similar to a focal myelitis, 
or, by affecting the blood-supply of the posterior arterial field, set up 
the changes in the posterolateral portion of the cord that induce com- 
bined scleroses. Ordinarily, spinal syphilis is multiform, and a varied 
picture is presented through the implication of various parts of the 
cordal apparatus. The matter is still further complicated by the varia- 
tions in a single case, which may at different times present great modi- 
fications. Thus a case beginning as meningitis may become a meningo- 
myelitis, set up a combined sclerosis, and terminate by focal softening, 
consuming many years in its history. For descriptive purposes, and 
based upon clinical manifestations, we may divide cases of spinal syphilis 
into : (1) Meningitis and meningomyelitis, (2) acute myelitis, and (3) 
ataxic paraplegias or combined scleroses. 

Syphilitic Meningitis and Meningomyelitis. — These furnish the 
most habitual expressions of spinal syphilis. In clinical features they 



496 DISEASES OF THE GENERAL NERVOUS SYSTEM. 

differ but little save in the absence of fever from similar lesions arising 
from any other source. The principal symptoms are pains and palsies. 
The pains are onset features and are of extreme intensity, usually with 
a well-marked tendency to nocturnal exacerbation. They are usually 
located in the lower extremities, but with these there is generally asso- 
ciated a most intolerable rachialgia in the lower part of the back. They 
are root pains and may be marked by tenderness along the nerve-trunks, 
and even by herpes and glossy skin. Partial palsy of certain muscle 
groups, with disturbed sensation in the cutaneous area of identical 
innervation, is occasionally seen, and still further confirms the neuritic 
and root disturbance. 

The palsies are rarely complete. There is a feeling of weakness in the 
legs, sometimes distinctly greater on one side than on the other ; a para- 
plegic distribution that may ascend to any level, but most frequently 
remains below the waist-line. In rare cases the upper members are most 
or alone affected. In some cases a pachymeningitis cervicalis has been 
found, with its characteristic deformities, and in some such instances the 
spinal portion of the dural disease has been a downward extension from 
syphilitic thickening within the skull. 

The cord is frequently affected, as is shown by bedsores, sphincter 
disturbances, Brown-Sequard paralysis, and a tendency to spasticity in 
the lower extremities, which are at first relaxed and enfeebled. 

The sensory disorders usually open the program and the paraplegia is 
ushered in by a feeling of heaviness and clumsiness in the legs. Usu- 
ally there are a series of remissions and advances until the spasmodic 
paraplegia is finally established. 

Occasionally, gummata form in the meninges and give rise to tumor 
symptoms or the Brown-Sequard syndrome. Multiple miliary gummata 
are still rarer. 

In the annular invasion of the cord the blood-supply is interfered 
with, both arteries and veins suffering from deformity and endothelial 
changes that may lead to ischemic softening and hemorrhage. Com- 
bined scleroses are similarly induced. 

Syphilitic acute myelitis, or softening, is not a rare condition. 
The best of recent observations indicate that the origin is in throm- 
botic occlusion of blood-vessels, syphilis acting as any other infection, 
or by setting up a specific arteritis or phlebitis, with or without accom- 
panying meningitis. In the softened area there is commonly great 
syphilitic cellular activity, and secondary hemorrhage frequently causes 
a hematomyelic condition. The favorite location for softening is in the 
gray substance, and the thrombosis may extend to all the vessels of a 
considerable area. Very rarely does the lesion involve the entire cross- 
section. Secondary ascending and descending degenerations naturally 
follow. 

The symptoms are those of an acute myelitis : sudden onset, para- 
plegia, corresponding sensory disturbances, sphincteric incontinence, and 
spasticity after a few weeks. 

Syphilitic Ataxic Paraplegia. — This variety of spinal syphilis 
has been much written about since Erb, in 1892, called attention to its 



SYPHILIS OF THE NERVOUS SYSTEM. 497 

frequency and uniformity. He proposed for it the name of syphilitic 
spinal paralysis. Subsequent communications by Muchin, Kuh, Kowa- 
lewski, and others tended to give it an autonomy that Erb specifically 
deprecated in his earlier reports. Subsequently 1 he asserted for it the dig- 
nity of a distinct clinical type due to primary changes in the lateral tracts 
of the cord following syphilis in the same sense that posterior sclerosis 
is post-syphilitic. Oppenheim, Brissaud, Marie, and others have denied 
its entity. 

The condition is usually of insidious onset, developing in a few 
weeks, months, or years. The first symptoms are feelings of heaviness 
and paresthesia in the legs, very soon accompanied by difficulty in 
emptying the bladder through spasmodic action of sphincter and de- 
trusor. Rigidity and spasticity in the legs soon develop, and the gait 
shows them in the dragging toes, adducted knees, and uncertain steps. 
Knee-jerks, rectus and ankle-clonus, and the toe-sign are commonly 
well marked and muscular strength is more or less reduced. Spasticity 
and a lack of muscular strength are especially insisted upon by Erb. 
Sensory disturbances are slight or entirely absent, and the disease is very 
slowly progressive or inclined to be stationary or to even improve under 
treatment for syphilis. It seldom reaches a stage of complete helpless- 
ness. Often the upper extremities are affected in a less degree, and 
pupillary symptoms are not uncommon. 

In this outline it is easy to see the symptoms of posterolateral scle- 
rosis or ataxic paraplegia, or the combined scleroses (see p. 463). The 
condition may also arise secondarily from a meningomyelitis, and it is 
clearly due to vascular disturbance in the posterior arterial cord-field, 
with the ataxia, spasticity, and paraplegia that mark such lesions. 

Diagnosis. — The diagnosis of spinal syphilis is frequently of the 
greatest difficulty. Unlike cerebral syphilis, it has not a characteristic 
premonitory stage. The nocturnal rachialgia and the advance and 
retreat of the spinal symptoms have some significance, but a history or 
the evidence of syphilitic infection has more weight and the presence 
of encephalic disease has most of all. This last, as already frequently 
stated, rarely defaults. In the combined scleroses we must exclude 
tabes, which can usually be done by a tap on the knee and an examina- 
tion for objective signs. Blood and spinal fluid tests have a very great 
value, particularly the finding of an increased cellular content in the 
cord fluid. To this commonly, almost invariably, are added Wasser- 
mann's positive in blood and spinal fluid and the positive globulin 
reaction. (See page 494.) 

Prognosis. — The outlook in focal myelitis is the same as in that 
lesion from other causes than syphilis, and depends upon the amount of 
damage to the cross-section, the vertical location, and the secondary 
degenerations. Meningomyelitis can frequently be held in check and 
offers a good prognosis if the cord is only superficially injured. The 
prognosis of the combined scleroses is good as to life, but bad as to 
complete recovery. 

Syphilitic neuritis is not a common accident. In rare instances 
1 "Br. Med. Jour.," Oct. 11, 1902. 
32 



498 DISEASES OF THE GENERAL NERVOUS SYSTEM. 

the toxic condition may induce a multiple neuritis. Cestan 1 was only 
able to collect 14 cases from the literature, but in minor degree it is 
probably not infrequent. Usually single nerves, as the sciatic, inter- 
costal, or some branch of the brachial plexus, are affected, and such 
lesions are often bilateral. 

Hereditary Cerebrospinal Syphilis. — Hereditary syphilis is 
capable of provoking any and all of the injuries of the general nervous 
system that follow the acquired infection, and, like it, is often marked 
by a multiplicity of lesions in a given case. These may appear con- 
genitally, in the early years of life, or be tardy and postponed until 
puberty, or even to the twentieth and thirtieth year. The presence 
or history of other syphilitic stigmata, such as Hutchinson's teeth, 
hydrocephalus, idiocy, cachexia, syphilitic skin diseases, choroiditis, and 
a history of parental syphilis, must often be relied upon for a diagnosis. 
This is confirmed by the four characteristic blood and spinal fluid 
findings of cerebrospinal syphilis. The lesions of hereditary syphilis 
are less amenable to treatment and of worse prognosis than those of 
the acquired form. 

Treatment of Active Cerebrospinal Syphilis. — The moment 
syphilis of the cerebrospinal apparatus is discovered, or even strongly 
suspected, intensive treatment should be instituted. The diagnosis of 
brain-syphilis implies the recognition of a critical condition. A num- 
ber of details are important to secure toleration and to maintain the pro- 
longed use of specifics. If the case be urgent, — and in view of the 
location of the disease it invariably is, — both iodids and mercury should 
be used at once. If the lesion is arterial, preference should be given 
the iodid of sodium, as the potassium salts have a tendency to increase 
arterial tension, and the sodium is also usually better tolerated. The 
writer's plan is to commence with 20 grains three times a day, and in- 
crease the dose 10 grains daily until, in rebellious or critical cases, 100, 
or even 200, grains are given at a dose. If the remedy be taken in a 
half pint of milk, or, better, in carbonated or aerated water, such as 
Apollinaris or Vichy, or even in the common siphon Seltzer, and after 
meals, there is rarely any difficulty even with the enormous doses indi- 
cated. Should a diarrheal tendency appear, it can be readily checked 
with bismuth preparations. Large doses of the iodids are much less 
likely to seriously disturb the patients than those of 7 to 15 grains. 
Mercury can be reliably exhibited by inunctions of 30 or 60 grains of 
the ointment daily. Various portions of the body, as the flanks, the 
back, and the extremities, should be used in rotation day after day. The 
danger of salivation can practically be eliminated if careful attention is 
given to the teeth and mouth. The use of mild antiseptic preparations, 
such as glycozone or boric acid, applied with a soft tooth-brush, and in 
gargles after taking food, is usually sufficient if the teeth are in good 
order ; otherwise a dentist should be called in at once. The chlorate of 
potassium pastes and dentifrices are also useful. 

The long-continued use of either iodids or mercury, singly or com- 
bined, is injudicious. After the first two or three weeks the mercury 
1 "Nouv. Icon, de la Salpet.," 1900. 



SYPHILIS OF THE NERVOUS SYSTEM. 499 

may be stopped and the iodid continued for another three weeks at such 
a dose as the progress or remission of the disease or the patient's toler- 
ance indicates. It should then be discontinued and mercury may again 
be employed. It is clinically proved that the syphilitic process can 
gain such a tolerance for either mercury or iodid that their specific effect 
is lost. Hence the imperative need of intermissions or alternations in 
their employment. Personally, the writer does not feel safe in the treat- 
ment of these cases without the use of both remedies. By alternation 
they seem to be mutually helpful. 

If the case progress favorably, the iodid for six weeks and the 
mercury for three weeks may be alternated in full doses for six months. 
The value of salvarsan or neosalvarsan is clear, it undoubtedly is of 
importance in the treatment of these cases. Conjoined with courses 
of mercury and iodid it offers the patient the best prospect afforded 
by modern medicine. The patient must be under medical observation 
for the rest of life, and under the guidance of the blood and spinal fluid 
tests and clinical indications treatment is to be repeated from time to 
time. Any reappearance of syphilitic activity should call for an im- 
mediate return to the intensive treatment. 

In place of inunctions, intramuscular administration of mercury 
may be used. In cases of great urgency injections should always be 
employed at first. Bichlorid or other soluble salt of mercury in doses 
of yq to | grain may be injected into the muscles daily to secure 
prompt effects. The intravenous injection of mercurial preparations 
is perhaps, of all methods, the most certain and efficient, but is not devoid 
of danger. It is claimed for it that in some instances in which all other 
methods have failed it produced immediate and lasting benefit. Slight 
looseness of the bowels does not contraindicate mercury, nor acne 
mean iodism. The slightest tenderness in the gums should lead to the 
immediate and complete cessation of mercury, to the use of which, with 
caution, the physician may usually return in a week. 

In fighting syphilis we should never forget the patient. At times 
all specifics must be withdrawn and the general system built up. This 
is sometimes necessary where the limit of toleration appears to be 
reached and the symptoms of specific activity are still progressing. 
Supportive measures are indicated at all times. Ferruginous tonics, a 
liberal diet, massage, salt baths, and frictions are all valuable. The use 
of large quantities of drinking-water, hot or cold, and the employment 
of hot baths, or Turkish baths, if they can be borne, are of assistance 
and often enable the use of larger doses of specifics than could other- 
wise be exhibited. Here arise the benefits of thermal springs and similar 
resorts, at which, in addition, the patient is often freed from domestic 
and business worries. 

The results of cerebrospinal syphilis in the way of plegias and nerve- 
atrophies require the same management as when arising from other 
causes. 

THE SO-CALLED PARASYPHILITIC DISEASES, 

Aside from the ordinary leutic lesions of the brain and spinal cord, 
there is the long list of so-called parasyphilitic diseases. These are not 



500 DISEASES OF THE GENERAL NERVOUS SYSTEM. 

marked by round-cell invasion and gummy process, nor are they so 
directly amenable to specific medication. They may develop heredi- 
tarily or, as is more commonly the case, follow acquired syphilis. A 
brief consideration is all that is required here, as they are individually 
dealt with elsewhere. 

Acquired Parasyphilitic Diseases. — Chief among these are tabes 
and paretic dementia, which are always postsyphilitic accidents. In 
the cachexia of lues the general physical depravity furnishes a favorable 
soil for the development of neuralgia, hysteria, and neurasthenia, which 
do not differ from the same neuroses arising independently of syphilis, 
but they are benefited or cured by the removal of the specific cachexia. 
They are usually attended by considerable mental depression, the 
mental equivalent of the muscular asthenia. 

According to Fournier, 1 in addition to the epileptoid manifestations 
of cortical invasion, there is an epilepsy peculiar to syphilitics. Its char- 
acteristics he outlines as follows: (1) It is unattended by other evidence 
of cerebral disease ; (2) it continues unchanged ; (3) it is of long dura- 
tion, even lasting the lifetime ; (4) it is not amenable to antisyphilitic 
remedies ; (5) the bromids have little control over it. Its onset is abrupt 
and usually in the form of a full epileptic seizure, without prodromata 
or inciting causes, and it often continues in the form of petit mal, grand 
mal, or a varying association of both. The attacks are commonly fre- 
quent during the first two or three years, after which they appear at 
long intervals only. Confirmation of this doctrine is lacking as yet, 
but cases corresponding to the outline are not extremely rare. 

Hereditary Parasyphilitic Diseases. — In this category can cer- 
tainly be placed the rare cases of juvenile tabes and paretic dementia. In 
addition all variations of deficient vitality and defective groicih may be due 
to parental syphilis. Notably traceable to that source are infantilism, 
mental defects, idiocy, hydrocephalus, and various cerebral and spinal 
agenetic states. 

1 " Les Affections Parasyphilitiques, " Paris, 1894. 



PART vn. 

DISEASES OF THE NERVOUS SYSTEM WITHOUT 
KNOWN NERVOUS ANATOMICAL BASIS. 



A large number of diseases clearly related to the nervous system 
and manifested on its part by disturbance of functional control are not 
marked by known changes in the neural apparatus. They are denomi- 
nated neuroses or functional nervous diseases. It is better to avoid the 
term functional, as it tends to distract attention from the probably exist- 
ing anatomical basis of these diseases. There is little doubt that sooner 
or later they will be histologically classified. The present arrangement 
is for utility only. The following table serves to group the neuroses for 
descriptive purposes. 

NEUROSES. 



I. Trophoneuroses. — Marked 
by trophic faults and 
changes in physical con- 
formation. 



Glandular. 



Vascular. 



II. Infection Neuroses.— Mainly marked bj 
motor disturbance. 



III. Motor Neuroses 



IV. Fatigue Neuroses. 



V. PSYCHONEUROSES 



VI. Neuroses Following Traumatism 



f Acromegalia, 

Adiposis dolorosa, 

Adiposity with genital dys- 
trophy, 
1 Myxedema, 
j Exophthalmic goiter, 

Scleroderma, 
[ Tetany. 

{Raynaud's disease, 
Acroparesthesia, 
Intermittent limping, 
Angioneurotic edema. 
{Hyperostosis cranii, 
Pulmonary osteo-arthropathy, 
Localized hypertrophies. 
Tetanus, 
Hydrophobia, 
Chorea, 
f Huntington's disease, 
j Myoclonia, 
<> Dubini's disease, 

Parkinson's disease, 
[_ Thomsen's disease, 
f Writers' cramp, 
I Occupation spasms, etc. 
r Neurasthenia, 
Psychasthenia, 
Hysteria, 
\ Epilepsy, 
j Migraine, 
LTics. 



501 



502 NEUEOSES. 

CHAPTER I. 
TROPHONEUROSES. 

In the group of neuroses marked by disturbances of nutrition some 
abnormality of the vasomotor control is commonly present. This may 
furnish nearly the entire symptomatology, as in angioneurotic edema, 
Raynaud's disease, and exophthalmic goiter. In other instances the 
vascular element is apparently small, and the processes of nutrition are 
principally disordered. The relation of nutrition to vascularity, how- 
ever, is always intimate. We can not as yet positively say through 
what individual strand of fibers trophic control is maintained, but it must 
be in close touch functionally with the vasomotor nervous apparatus. 
Certain groups of trophoneuroses are directly related to the chain of 
ductless glands : one group principally to the pituitary body, another 
to the thyroid and parathyroids. 

Trophoneuroses Related to the Hypophysis Cerebri. — The func- 
tion for the pituitary gland has been practically unknown until very 
recent years. Anatomically, it consists of — (1) a posterior lobe of 
nervous tissue; (2) a middle portion or septum of epithelial character, 
outgrowing from the buccal sac; and (3) of an anterior epithelial lobe 
of similar origin and constituting a remnant of the primitive or embryonic 
mouth parts. This anterior glandular portion formerly discharged its 
secretion into the mouth, and a rudimentary duct is still traceable in 
some subjects. 

The posterior portion, the pars nervosa, furnishes a principle sim- 
ilar to the product of adrenalin that raises arterial tension. This 
secretion reaches the nervous apparatus through the infundibulum 
and third ventricle. It also seems to control fat accumulation. The 
anterior lobe, the pars anterior, has an intimate association with bony 
growth and with sexual activities. The pars intermedia appears to be 
related to the excretion of urine and the function or control of sugar 
tolerance. The pituitary in its varied functions is also related to the 
activities of all the other ductless glands of the body, the thyroid, para- 
thyroids, thymus, adrenals, islands of Langerhans, ovaries, and testicles. 

Overactivity of the hypophysis, or hyperpituitarism, apparently 
causes the remarkable changes of acromegaly; underactivity, hypo- 
pituitarism, causes failure of development and asexual characteristics, 
sometimes with increased deposition of fat. These states are modified 
and clinical variants are induced by the period of life and the state of 
growth present when the morbid glandular condition becomes opera- 
tive, and further differences are due to the degree of functional glandular 
perversion and to the varying degrees in which the diverse pituitary 
functions are affected. A series of cases with many overlapping features 
may, therefore, be encountered from one end to the other of extremes of 
hyper- and hypopituitarism. Life is probably not possible with com- 
plete loss of the hypophysis. In dogs apituitarism caused by the re- 
moval of the anterior lobe causes a fatal cachexia (Cushing, Paulesco). 

The lesion causing pituitary disease is commonly a neoplasm begin- . 
ning in the gland itself or in its vicinity. Thereby many "neighbor- 



TROPHONE U ROSES. 



503 



hood" symptoms are added, such as disturbance of the visual fields by 
the implication of the chiasm or optic tracts, especially hemianopsia, 
headaches, and stuporous conditions from endocranial pressure, and dis- 
tention of the sella turcica. In other instances new growths are not 
found, but glandular changes are present, showing particularly in cel- 
lular modifications. 

As pituitary diseases we may tentatively group acromegalia, Froeh- 
lich's dystrophia adiposogenitalis, infantilism, and Dercum's disease. 

ACROMEGALIA. 

In 1886 P. Marie 1 called attention to two cases presenting acquired 
symmetrical enlargement of the hands, feet, and face, and proposed the 




Fig. 209, a.— Giantism, infantilism, and acromegaly in a patient twenty-one years old, standing 
beside his older brother (M. Lemos). 



name acromegalia, which has now become current. His description of 
these cases was so full that little has since been added to the clinical 
side of it. Similar cases were at once recognized all over the world. 
In 1892 Collins 2 was able to collect about ninety cases from literature. 
Since then the material has rapidly increased, and many autopsies have 
been put on record. 

1 " Revue de Med.," 1886. 2 " Jour. Ment. and Nerv. Dis.," N. Y., 1892. 



504 NEUROSES. 

Etiology. — The causation of the disease is extremely obscure. 
Alleged or supposed inciting causes are almost as numerous as recorded 
cases, and embrace well-nigh every ordinary and exceptional experience 
of human life ; consequently, no importance at present attaches to any 
of them. Both sexes are about equally affected. The disease makes 
its appearance customarily between the ages of eighteen and thirty. 
Exceptional cases have developed in advanced life and others in child- 
hood. Several have appeared so early that they have been considered 
congenital. Occasionally brothers (Fraenkel) or parent and child have 
been similarly affected. 1 It has been found in association with tabes, 
syringomyelia, rachitis, gigantism, exophthalmic goiter, goiter, and vari- 
ous psychoses. 

Klebs, impressed by his first case in which the thymus gland per- 
sisted, and Erb by the area of sternal dullness in other cases, were dis- 
posed to consider the changes in the bones and soft parts as due to a 
thymic angiomatosis. Later cases failed to present the enlarged thymus, 
and the sternal dullness is probably sometimes due to thickening of the 
bone itself. Some, with Freund, have attributed the somatic changes of 
acromegalia to inversion in the evolution of genital life. Recklinghausen 
considered it an angioneurosis dependent upon central changes. These 
changes are not found, and angiomatosis is not evident in the tissues. 

The usual adenomatous enlargement of the pituitary body and the 
frequent defective or goitrous condition of the thyroid have led to the 
belief that acromegalia is a trophoneurosis dependent upon modifications 
of the functions of these glands, especially of the pituitary. Kogo- 
witsch, for example, considers that these glands destroy certain sub- 
stances which have a toxic influence on the central nervous system. 
Others think that they secrete certain substances needful to the proper 
action of the trophic apparatus. All that can now be said is that the 
prehypophysis cerebri is nearly if not always hypertrophied, but whether 
as a cause or result is not determined. It is true, however, that tumors 
and other destructive conditions of the pituitary have been found with- 
out acromegalia. 2 That there is a definite relation between the pituitary 
gland and general growth and sexual development is quite evident from 
cases of pituitary disease associated with infantilism and defective gen- 
itals. Such cases are reported by Hudovering, Fuchs, Haushalter, Lucien, 
and Froehlich. 3 Caselli contends that the pituitary gland is essential to 
life in dogs and cats, while Freidman and Maas 4 deny it. Israel 5 re- 
ports a well-marked case of acromegaly under observation for some 
years in which the pituitary gland was normal. Lewis 6 called attention 
to marked hyperplasia of the chromophile cells of the glandular portion 
of the hypophysis, which otherwise appeared normal, seeming to confirm 
the theory that acromegaly is caused by the excessive function of the 
glandular elements of this organ. The masterly studies, animal experi- 
ments, and operations of Cushing 7 make it evident that excessive activ- 

1 Franchini and Giglioli, " Nouvelle Iconographie de la Salpetiere," Oct., 1908. 

2 Jokoloff, " Virchow's Archiv," Bd. xliii. 3 " Kev. Neurolog.," Jan. 15, 1908. 

4 " Berlin, med. Woch.," 1900. 5 " Virchow's Archiv," vol. clxiv, 344. 

6 " Johns Hopkins Hosp. Bull.," Mar., 1908. 7 Ibid.. May, 1910. 



TROPHONE U ROSES. 



505 



ity of the pituitary is associated with abnormally increased growth, 
under- or hypopituitary activity, with retarded growth, and both with 
genital inactivity. It is also evident that there are functional links 
between the pituitary, thymus, thyroid, and genital glands. 

Morbid Anatomy. — The bones of the face, cranium, extremities, 
and to a lesser degree those of the trunk, show hypertrophy. The 
frontal and occipital bones are commonly thickened and their markings 
exaggerated. The frontal and maxillary sinuses are enlarged and the 





Fig. 210. — 1, Base of cranium showing excavation of the sella and, 2, pituitary tumor in a case of 

acromegalia (Marie). 

pituitary fossa is greatly increased in size. The inferior maxilla, the 
malars, the zygomatic arches, and the superciliary ridges of the frontal 
are particularly enlarged. There is commonly elongation of the 
spinous processes in the cervicodorsal region, and the bodies of the 
vertebrae are sometimes increased in the anteroposterior diameter. The 
ribs, clavicles, and sternum are commonly, and the shoulder-blades 
occasionally, enlarged. In the limbs the hypertrophy is most marked 
toward the distal extremities. The long bones of the leg and forearm are 
most changed at their lower ends. The metacarpals, metatarsals, and 
phalanges are particularly involved. Histologically, the hypertrophy 
is a true one, bone being deposited under the thickened periosteum and 
the central canal enlarged by the action of osteoblasts. 

The pituitary gland is enlarged and hypertrophic, filling up the dis- 
tended and enlarged sella turcica and commonly compressing the optic 
chiasm and adjoining structures. It practically constitutes an endo- 
cranial tumor. Strumpell 1 is inclined to think it an essential finding. 
In many cases it has been found to have undergone changes, probably 
secondary in point of time and nature. Tamburini 2 believes the first 
stage is one of enlargement and increased function, followed by adeno- 
matous, sarcomatous, or cystic degeneration. A number of cases show- 
ing such degenerative changes are cited by Strumpell 3 and reported by 
others. In all cases the pituitary is diseased. 



1 " Deutsche Zeit f. Nervenheilk.," 1897. 

2 " Centralblntt f. Nervenh.," Dec., 1894. 



3 Loc. cit. 



506 



NEUROSES. 



In the extremities and other portions affected by the hypertrophic 
enlargement the skin in its epithelial, dermal, glandular, and muscular 
parts is hypertrophically exaggerated. The connective tissue particu- 
larly is increased. The subcutaneous nerve-filaments are sometimes de- 
generated as a result of the fibrous hyperplasia, but this does not extend 




Fig. 211. — Skiagraphs of hands : A, Case of acromegalia ; B, normal hand. 



into the nerve-trunks. The skin is frequently overactive and the per- 
spiration may be excessive and disagreeably fetid. In color the skin is 
usually muddy, especially toward the extremities, and frequently marked 
with warts and pendulous, soft fibromata. The cutaneous sensibility is 
practically normal, but these patients are usually very sensitive to cold. 
The mucous membrane of the nasopharynx, larynx, and tongue are simi- 
larly affected. The kidneys often show a moderate chronic parenchy- 
matous nephritis, with interstitial fibrosis. The spleen and lymphatic 
glands may be sclerosed; the thyroid is usually atrophic or goitrous; the 
thymus may persist and even be enlarged. It is to be noticed that, 
while parenchymatous glandular structures generally are atrophic, 
the pituitary is hypertrophic. 

Symptoms. — Among the most common symptoms of acromegalia 
we may name hypertrophy of the face, hands, and feet, visual defects, 
dorsal kyphotic deformities, persistent headache, sexual failure in men, 
and amenorrhea in women. 

The face is notably deformed. The greatly enlarged, overhanging 
brows are marked by shaggy, coarse eyebrows. Thickened eyelids ; some- 
times exophthalmos ; sl heavy, large, flabby nose ; great cheek-bones ; an 
enormous mouth, correspondingly thickened lips, and a much enlarged and 
prognathic lower jaw are some of the facial characteristics. The heavy 
features, puffy face, and accentuated nasolabial folds give an expression 
of grief and suffering. When the mouth is opened, it is seen that the 



TROPHONEUROSES. 



so: 



hypertrophic enlargement of the Jaw's, especially of the mandible, causes 
the teeth to stand separately and at considerable intervals. The mucous 
membrane is also thickened and the tongue is notably enlarged, in some 
instances reaching an enormous size. The soft palate, pharynx, aud 




Figs. 212 and 213.— Faces in acromegalia, two cases. Note enlarged superciliary ridge, thickened 
lips, massive jaw, and general grossness. 



larynx equally share in the hyperplasia, and the tonsils and follicular 
structures are also increased in size. The ears and occiput are some- 
times enlarged, sometimes not. The scalp is thickened, the hair coarse, 
thick, and harsh. The complexion is usually sallow and the parts are 
elastically doughy to the touch, showing no pits on pressure. 

The hands are greatly enlarged in all their dimensions, but particu- 
larly in width. The proportion of fingers to hand and hand to wrist 
is retained ; they are, therefore, enlarged symmetrically. The fingers 
are thick and sausage-shaped, the hand thick and beefy, the thenar and 
hypothenar eminences greatly but proportionately enlarged. The whole 
hand is described as " spade-like or battledore-shaped." This appearance 
is sometimes intensified by a comparative thinness of the forearms. The 
joints are never limited in their range of motion, and the parts are sur- 
prisingly supple and flexible. The palmar furrows are usually much 
deepened, the skin thick and resilient, the hairs coarse, the nails broad- 
ened, thick, and strongly striated longitudinally. 

The feet show similar changes, and usually there is a heavy welt of fibro- 
elastic increase around the heel and along the outer border of the foot. 

The thorax usually presents an anteroposterior curvature in the cer- 
vicodorsal region, which may be compensated by lumbar lordosis and 
attended by scoliotic twists. The clavicles are almost invariably increased 
in thickness and sometimes in length, and the sternum may also share in 
the hypertrophy. The ribs and cartilages are often enlarged. These 
bony changes give the chest an unusual breadth and anteroposterior 
depth. The respiration is ordinarily abdominal in character, and the 



508 



NEUROSES. 



abdomen is often protuberant or even pendulous. The pelvic girdle may 
be enlarged. 

The external genitalia in women are ordinarily hypertrophied, the 
uterus atrophic. In men there may be hypertrophy or atrophy of the 
external genitals. Amenorrhea and sterility are the rule with women, 
sexual inappetence and impotence with men. 

Cephalalgia of an intense, persistent, deep-seated character is present 
in the great majority of cases. 




Fig. 214. — 1 and 2, Hand in acromegalia ; 3, foot in acromegalia. 



Speech is frequently thickened from the clumsiness and voluminous 
size of the tongue, and the voice is ordinarily very deep, strong, and 
rough, owing to the enlargement of the larynx, which to palpation may 
appear of increased dimensions and unusual prominence. 

The organs of special sense may all be affected. Smell, taste, or hearing 
may be reduced or abolished, but this is uncommon. Vision, however, 
is usually more or less affected eventually. This may arise from opAic 
neuritis or from atrophy, and in either case points to encephalic tumor. 
Amblyopia, blindness, intra-ocular pains, exophthalmos, contraction of 
the visual field, unilateral, homonymous, and bitemporal hemianopsia, and 
miosis have been noted. The bilateral loss of the temporal fields or their 
manifest reduction indicates injury to the chiasm by the pituitary tumor. 

The muscular system may be normal or some atrophy may be found, 
but general muscular weakness is the rule. The reflexes are normal or 
diminished. The electrical responses are frequently quantitatively re- 
duced. Cardiac hypertrophy, arteriosclerosis, varicose veins, and slight 
lymphatic adenopathy may be encountered. High arterial tension is 
the rule until terminal stages are reached, when a flabby heart and 
attacks of syncope are frequently encountered. The thyroid may be 
absent, normal, or hypertrophic. Polyuria, glycosuria, polydipsia, excess- 
ive appetite for food, and dyspepsia are common. 

General physical feebleness is usual, and mental sluggishness, irrita- 
bility, and inaptitude are common. 



TROPHONE U ROSES. 



509 




Fig. 215. — Cervicodor- 
sal curvature of spine ; chest 
and abdominal distortion in 
acromegalia (Marie). 



Course and Forms. — The disease is of insidious onset and slow 
progression, presenting a duration of twenty to thirty years and ter- 
minating by a cachectic state marked by great 
muscular weakness, during which death often 
occurs suddenly through cardiac failure. Inter- 
current affections find acromegalics very vul- 
nerable. 

We may distinguish two varieties of acrome- 
galia, depending mainly upon the age at which 
the disease commences and the condition of epi- 
physeal ossification with the diaphyses : (1) Before 
complete ossification takes place the enlargement 
is not only in lateral dimensions, but also in 
length, and the limbs become disproportionate to 
the body, producing gigantism. Autopsical find- 
ings by Hutchinson, Dana, Bramwell, Taruffi, and 
skiagraphical investigations by Marinesco conclu- 
sively show this relation. (2) After the diaphy- 
ses and the epijmyses are united by bone, only 
circumferential increase is produced, and the 
stature, from scoliosis, may actually be reduced. 
The commoner massive type originally described is 
then developed. 

Diagnosis. — The diagnosis can rarely present 
difficulty if the disease has attained any consider- 
able degree of development. Myxedema shows no 

osseous deformities, and the thickening of the soft parts is waxy and 
boggy. Pulmonary osteo-arthropathy presents joint-changes and a chronic 
pulmonary process. The clubbed enlargement of the fingers is largely 
confined to the terminal phalanges, over which the hypertrophic nails 
hang like parrot-beaks. In hyperostosis cranii the hands, feet, and 
mandible are not affected. Paget' s disease, or osteitis deformans, spares the 
face, but affects the skull, and causes bowing of the long bones, especially 
the femora and tibiae. The x-ray commonly shows excavation of the 
sella. 

Prognosis. — The progress, as above indicated, is toward physical 
helplessness and mental depression, which in more than one instance 
have led to suicide. According to Thompson, 1 the disease may run an 
acute, intermittent, or chronic course, lasting from two to thirty years. 
Sudden death from cardiac failure is rather frequent. 

Treatment is directed to .relieving the cephalalgia and correcting the 
symptomatic disturbances as far as possible. For the first, phenacetin 
and similar synthetical anodynes seem to be most efficacious. Treatment 
by thyroid or thymus, singly or combined, seems to be of little avail, 
except in some instances to reduce weight, and then often at the expense 
of the general health and strength. The surgical removal of a part or of 
all of the anterior lobe of the pituitary gland, or of the pituitary tumor, 
has been made possible by the brilliant achievements of Horsley, Schlof- 
fer, Eiselberg, Kanavel, Halsted, and Gushing. Operation is indicated 
1 "Brit. Med. Jour.," April 9, 1899. 



510 NEUROSES. 

in those cases which present marked symptoms of advancing brain 
tumor, particularly optic neuritis, or beginning optic atrophy and 
threatened blindness. It may also be undertaken to control the gen- 
eral acromegalic state, as already several operated cases are recorded in 
which there has been an actual recession of the bony and soft tissue 
enlargements. After hypophysectomy, the patient's condition must be 
watched and hypophysis feeding employed if the cachexia of a hy- 
pophysism appears. 

ADIPOSITY AND GENITAL DYSTROPHY. 

The relations of the genitals to the pituitary are abundantly estab- 
lished by clinical observations and animal experiments. Amenorrhea in 
female and impotence in the male subjects of acromegaly is a common 
observation. Some of the youthful giant cases never develop sexually. 
Castrated bulls and cocks show pituitary enlargement, and, on the other 




Fig. 216. — x-Ray picture of normal sella turcica, marked +. 

hand, dogs subjected to partial excision of the hypophysis cerebri become 
fat and asexual with atrophic genitals (Cushing). 

Juvenile cases presenting general adiposity and undeveloped genitals 
have been of occasional mention in literature, but Froehlich * first called 
attention to their relation to pituitary disease. Marburg 2 divides such 
cases into three classes : (1) Simple adiposity, (2) adiposity with genital 
atrophy, (3) simple genital atrophy. To these must be added (4) in- 
fantilism, or a simple lack of physical and sexual growth (Church 3 ). 
Marburg further enunciated the formula that hyperfunction of the pitu- 
itary resulted in acromegaly ; hypofunction in general adiposity and 
genital dystrophy, complete pituitary defect in a severe cachexia anal- 
ogous to that after destruction or ablation of the thyroid. All these 
juvenile conditions are related to a lack or, in some instances, perhaps 
to only a perversion of pituitary control. Some of them present distinct 
symptoms of a pituitary tumor, such as hemianopsia, cranial nerve pal- 
sies, and the diffuse symptoms of brain tumor, especially headaches, 
vomiting, and convulsions. The #-ray plate (Figs. 216 and 217) often 

1 " Wien. klin. Kundsch.," 1901. 2 " Deutsch. Zeitschr. f. Nervenheilk.," 1908. 

3 " Jour. Amer. Med. Assoc," 1910. 



TROPHONEUROSES. oil 

gives a vivid picture of excavation of the sella turcica. A pituitary 
tumor is not necessarily present. This gland may be compressed by 
an adjacent growth or influenced by a variety of pathological conditions. 
Similar conditions arising after the attainment of full sexual growth 
cause, in varying degree, sexual inaptitude, genital atrophy, impotence, 
and amenorrhea, and may cause more or less obesity. 




Fig. 217.— jr-Ray picture of sella turcica, marked — . excavated by pituitary tumor. No acro- 
megaly present. 

The treatment must be carefully individualized. Brain tumor con- 
ditions must be treated on their own surgical indications. Decom- 
pressive operations are advisable in some instances. AVhen the tumor 
is definitely limited to the pituitary, it offers an opportunity for a 
brilliant operation and an equally brilliant result. The cachexia 
resulting upon a lack of pituitary function must be combated by 
pituitary feeding, and this may be tried in the infantile or juvenile 
case-. 

Adiposis Dolorosa. — In 1892 F. X. Dercum, 1 under the title 
Adiposis Dolorosa, described a condition which seems in the adult to be 
analogous to the adiposity and genital dystrophy of Froehlich which 
occurs in earlier years. This condition has come to be generally known 
as Dercum" s disease. 

In the etiology, neuropathic heredity or a personal neuropathic con- 
dition have not been noted with sufficient frequency to make them 
highly significant. AVomen are more often affected than men in the 
proportion of 6 to 1. The condition develops usually between the ages 
of thirty-five and fifty, though cases, both younger and older, are recorded. 
Women who have passed the menopause furnish the largest number. 
Alcoholism and syphilis have been present in a considerable number of 
instances, and their action in producing degeneration of the ductless 
glands seems to be established. 

Adiposis dolorosa is of insidious development. The principal symp- 
toms are a sensitive fatty deposit, pain, general asthenia, genital dis- 
turbances, and psychic disorders. The fatty deposit may be nodular, 
circumscribed, or diffuse. Some of the patients attain great weight, but 
1 " Amer. Jour. Med. Sciences," 1592. 



512 



NEUROSES. 



in many the body weight is not materially increased, especially in the 
nodular form. The fatty deposits are most commonly found over the 
trunk, shoulders, arms, and thighs, forearms and legs being less fre- 
quently affected, hands and face rarely. The fatty masses show a pecu- 
liar tendency to bruise readily. They present the peculiarity of being 
sensitive to manipulation and touch and frequently the seat of sponta- 




Fig. 218.— Adiposis dolorosa of the diffuse truncal form (Dercum). The anterior view shows 
the peculiar apron of fat and the small size of the hands. The posterior view shows the arrange- 
ment of fat in folds over the hips. 

neous pains. The nerve trunks ordinarily are not sensitive, but may be 
so. Diminished sensation and paresthesias are frequent. The patients 
complain of numbness, coldness, crawling, tingling, etc. General weak- 
ness is commonly complained of. In both sexes sexual activities tend 
to subside in a degree out of proportion to the age of the patient. The 
mental changes are various, embracing depression, loss of memory, mel- 
ancholia, delusional insanity, and dementia. Epileptic convulsions, blind- 



TROPHONEUROSES. 513 

ness, deafness, and various organic changes in the central nervous system 
have been incidentally noted. The tendon reflexes, commonly diminished 
or abolished, sometimes are increased. Vasomotor disturbances are fre- 
quently encountered. Flushings, cyanosis, transitory edema, spontaneous 
hemorrhages from nose, stomach, and uterus, and absence of perspiration 
are not uncommon. Trophic changes, such as ulceration, the formation 
of blebs and bulla?, arthritic and bony changes, have been noted. Head- 
ache, dyspnea, rapid heart, insomnia, and tremor are not infrequent, and 
the symptoms of fatty heart may be expected. 

As to pathology, the reports of eight autopsies collected by Price, 1 
whose description is mainly followed herein, indicates involvement of 
the ductless glands in all in which they were examined. The thyroid, 
while commonly involved, at least in one case was normal. In all of 
the cases in which the pituitary was microscopically examined, it was 
found to be diseased either by neoplastic formation or cellular change or 
round-cell infiltration. Dercum is now disposed to look upon the dis- 
order as one due to hypopituitarism. 

The diagnosis is usually readily made if one bears in mind the 
association of painful conditions with deposits of fat, which are 
sensitive to pressure. The condition lacks the bony changes of 
acromegaly, and the painless, symmetrical, and uniform develop- 
ment of fat in ordinary obesity. The condition is not infrequently 
mistaken for rheumatism and frequently for multiple neuritis. The 
tendency of the disease is to permanency, and it does not directly cause 
death. Intermissions are rare, but remissions are common, and recovery 
has occurred only in one case (Dercum). 

The treatment of adiposis dolorosa by the administration of thyroids 
seemed to result successfully in the one case reported cured by Dercum, 
and improvement has been reported in a number of other cases under the 
same treatment. The administration of pituitary extracts or pituitary 
feeding is indicated. When a pituitary tumor can be detected, surgical 
treatment should be considered. Alcoholism and syphilis must meet 
their appropriate management, and the condition of the heart, with its 
tendency to fatty degeneration, requires supervision. The pains and 
tenderness are generally beneficially affected by the salicylates. 

TROPHONEUROSES RELATED TO THE THYROID AND PARATHYROID 

GLANDS. 

Among the ductless glands the function and diseases of the thvroid 
are of the greatest importance. Reduced functional activity of the 
thyroid is correlated "with a group of dystrophic conditions and nervous 
and mental symptoms which finds a type in myxedema. Complete 
athyroidism, as, for instance, that produced by ablation of the thyroid, 
produces a fatal myxedematous cachexia. Lesser degrees of thyroidal 
inactivity give a large range of variations, embracing cretinism and in- 
fantilism when occurring early in life, and slight myxedematous dis- 
orders at all ages. Thyroidal overactivity finds its typical clinical 
manifestation in exophthalmic goiter, a condition again that has a wide 
variation of degrees of intensity. 

1 "Amer. Jour. Med. Sciences," May, 1909. 



514 NEUROSES. 

Through the functional relation of the thyroid to the other ductless 
glands the various clinical manifestations of imperfect or disturbed 
thyroidation are variously complicated by association with acromegaly, 
Addison's disease, dyspituitarism, and abnormal thymic states. Sexual 
abnormalities are commonly also present. 

The various members of the chain of ductless glands apparently are 
able to substitute one another to a certain extent. They are also able 
mutually to stimulate each other, as has been proved by animal experi- 
ments and observations in disease by means of implantation and glandu- 
lar feeding. 

MYXEDEMA. 

Under the generic term of myxedema it is proposed to bring 
together those clinical variations of nutritive disorder dependent upon 
partial or complete cessation of thyroid activity. In 1873 Gull de- 
scribed a cretinoid state occurring in adult women. Four years later Ord 
reported additional cases and proposed the word myxedema (mucous 
swelling). Charcot, about this time, struck by the cutaneous thicken- 
ing and the cachectic state, used the term pachydermatous cachexia. 
In 1880 Bourneville and d'Olier described a case of myxedematous 
idiocy and subsequently many more. In 1882 Reverdin, and shortly 
afterward Kocher, reported myxedema following complete extirpation 
of the thyroid, for which they severally proposed the terms of operative 
myxedema and cachexia strumipriva. The analogies between acquired 
myxedema, myxedematous idiocy, and cretinism have been noted by 
many, and Brissaud, in his lectures of 1893— '94, brings certain cases of 
infantilism, or physical retardation, into the same category. We will 
commence by a description of acquired myxedema in adults. Due 
allowance being made for the age and growth of the individual, and the 
suddenness and completeness with which the thyroid is affected, will 
practically enable this description to be applied to all the above- 
mentioned varieties. 

Acquired myxedema of adults is of insidious onset, as a rule, 
and more common in women than in men. It usually appears between 
the ages of thirty and fifty. Occasionally it has abruptly followed an 
attack of acute rheumatism, some infectious fever, or a severe hemor- 
rhage. It is marked by : (1) Tumefaction of the dermal and mucous 
structures ; (2) by intellectual and physical enfeeblement, and (3) by 
atrophy of the thyroid body. 

The dermal changes are the most striking. The skin is infiltrated 
with a mucoid substance and the fatty panniculus is frequently greatly 
thickened. The swelling offers an elastic resistance to the touch and 
does not pit on pressure.' The color is usually pale, yellowish, and waxy 
or cheesy. The face is enlarged, rounded, and apathetic. The heavy, 
thickened lids droop over the eyes, the nose and lips are thickened, 
the brow is furrowed, the ears enlarged, and the cheeks rounded and 
showing jelly-like trembling on slight jarring. The whole appear- 
ance is one of hebetude and stupidity. The skin of the trunk and 
extremities is likewise infiltrated. In the axillae and subclavicular 
depressions lipomatous-like masses are often encountered. The hands 



TROPHONE U ROSES. 



515 



and feet are enlarged with cushion-like swellings on their dorsal surfaces; 
the digits are thick and clumsy. The scrotum is often much thick- 




Fig. 219.— A case of myxedema before and after two months' treatment by thyroids 
(Dr. Jobn Woodman). 

ened. The epidermal structures are greatly affected. The skin is dry, 
harsh, and branny. The hair becomes dry and scanty on all portions 
of the head and body. The nails are dry, fragile, striated, atrophic. 
Perspiration and sebaceous secretions are defective. The mucous mem- 
branes, wherever visible, are tumefied, pale, dry, and elastic. Mucous 
polypi in the nasopharynx are not uncommon. The tongue is thickened 
and, with the infiltrated condition of the buccal, pharyngeal, and laryn- 
geal mucous membranes, explains the muffled voice and difficulty of 
swallowing. 

The intellectual state in myxedema is uniformly marked by apathetic 
enfeeblement, and cerebral torpor shows itself in sluggish mentation, 
defective memory, slow speech, and lethargic movements. Myxedemic 
patients are usually indolent both mentally and physically, and are 
irritable and somnolent. Some cases show nocturnal insomnia and are 
troubled by disturbing dreams. The sluggishness of movement and 
the clumsiness of the hands and feet are due to the cerebral torpor and 
the local thickenings. These patients have no muscular energy and are 
promptly fatigued on the slightest continuous effort, but there is no 
palsy. 

The thyroid in the great majority of cases can not be detected by 
palpation. There may be a history of its former presence or actual 
enlargement, and even a goitrous condition may persist. In some in- 



516 NEUROSES. 

stances exophthalmic goiter has preceded myxedema and they have also 
been found associated, but Graves' disease does not follow myxedema. 

Less prominent and constant conditions in myxedema are : cardiac 
weakness, irregular pulse, hemorrhages (especially metrorrhagia), a sub- 
normal temperature, loss of teeth, habitual constipation, and occasionally 
albuminuria in advanced cases. The patients complain of headaches, 
vertigo, throbbing in the ears, and particularly and almost constantly of 
a sensation of cold. Sensations objectively, motor conditions, and the 
reflexes are normal. 

Usually insidious in onset, the disease runs a slow, tardy, progressive 
course. Remissions of longer or shorter duration may occur, as in 
summer, or by removal to a warm climate, and pregnancy sometimes 
has a similar retarding effect. The general tendency is toward 
cachectic helplessness and death by marasmus. In the very last stages 
the tumefaction may disappear. Pulmonary complications, especially 
tuberculosis, are common, and cardiac asthenia may strike the final 
note. Fortunately, treatment is now equal to the requirements of these 
otherwise hopeless cases. 

Operative myxedema is usually the result of the total extirpation 
of the thyroid, which it follows in from three to six months. Removal 
of a part of the thyroid, the remainder being completely disabled, — by 
cystic disease, for instance, — results in myxedema. This is initiated by 
lassitude, physical enfeeblement, sensations of cold, heaviness in the 
limbs, sluggish and clumsy movements. Shortly the integument tume- 
fies and becomes discolored, the hair falls, and cutaneous functions lag. 
The cerebral torpor follows and myxedema is fully established. Tetany 
may also develop, due, according to Murray, 1 to the loss of the parathy- 
roid bodies, which in man are sometimes included in the lobes of the 
thyroid. The relation of the parathyroids to tetany and their control 
of the calcium metabolism is definitely established by McCallum and 
Voegtlin. 2 The course is usually progressive, but is more subject to 
remissions than in the spontaneous variety. Other cases improve, 
owing to the compensatory action of unremoved portions of the gland, 
or to the development of accessory thyroids, or through the vicarious 
activity of other glandular structures. The gravity of operative myx- 
edema is great in proportion as the patient is young. Occurring in 
childhood, or at any period before adult life, it retards or completely 
checks growth, and produces a persistent infantilism or a myxedematous 
idiocy. It is, however, completely amenable to the thyroid treatment. 

Congenital myxedema, myxedematous idiocy, or sporadic 
cretinism is usually first noticed at about one year of age, or upon 
weaning, and thereafter presents all the characteristics of adult myx- 
edema, excepting that the mental faculties never develop and physical 
growth is retarded to the last degree. It is frequently congenital, and 
Horsley has found it in a dead-born fetus. It is encountered in the 
offspring of degenerate, alcoholic, or phthisical parents. At twenty years 
of age these cretinoid idiots may be of little more than two feet of 
stature. The relatively normal size of the head contrasts with the 
dwarfish body. The skull is full behind, contracted and narrow in 
1 "Brit. Med. Jour./' Mar. 18, 1899. 2 "Johns Hopkins Hosp. Bull.," Mar., 1908. 



TROPHOXE U ROSES. 



517 



front, often with persistent fontanel. The flabby, thickened features; 
snubbed nose, thick lips, drooping eyelids, mouth agap, lolling, hyper- 




Fig. 220.— Sporadic cretin before and after twelve mom hs' thyroid treatment : 1, Five years old ; 2, one 

year later (Parker). 

trophic tongue, and drooling saliva make up a peculiarly repulsive 
appearance. Add, now, the short, often lipomatous, neck ; a protuberant 
abdomen, often showing inguinal and umbilical ruptures ; a deviating 
spine, rudimentary genitals, and dwarfish, crooked limbs, and it is im- 
possible to imagine a less human-looking object with human attributes. 
Sparse hair, eczema, and an infiltrated, inactive skin are commonly 
present. The thyroid is absent. Idiots mentally, they can ordinarily 
exercise a little attention and even show some affection. In some in- 
stances they assist themselves in eating and dressing. They never 
learn to speak, and never show signs of pubescence. Often even the 
first dentition is extremely defective. On the other hand, they lack 
the destructiveness, noisiness, tics, convulsions, onanism, balancing and 
motor disturbances so common in idiocy from cerebral lesion. These 
unfortunate creatures may attain thirty or forty years of age, and 
usually die of pulmonary concomitants. 

The disease is also amenable in some degree to the thyroid treatment. 

Cretinism is a term of ancient lineage and honored usage, but of 
somewhat uncertain definition. It has been applied to the goitrous and 
feeble-minded natives of localities where goiter is endemic. Certain 
valleys in France, Spain, Italy, and Switzerland, and some parts 
of Great Britain, Sweden, and of other countries widely scattered 
over the globe present endemic conditions that predispose to goit- 
rous enlargements. Such an endemic has been noted in Minnesota 
and Ontario. A few definite facts are the results of observations 
extending over generations in some of these communities. The off- 
spring of two goitrous parents, according to Kocher, is invariably a 
cretin, who may or may not be goitrous, but is myxedematous. A 
non-goitrous cretin invariably has goitrous antecedents and is indistin- 



518 



XEU ROSES. 



guishable from the myxedematous idiot or sporadic cretin, the condition 
also being congenital. In the goitrous cretins the thyroid disease may 
appear at any period of life, and acts then, exactly as does spontaneous 
myxedema or operative myxedema, to stunt growth and stop mental 
development. The goitrous cretin is usually also myxedematous and 
may present any degree of mental impairment, from mere simple- 
mindedness to abject brutishness. The distribution of endemic cretinism 
is identical with that of endemic goitrous disease, and Kocher believes 
this to be due to organic infections through the water-supplies. The 
water origin of goiter was strongly supported by Bircher, but a more 
recent survey of the question, and particularly in Switzerland by Die- 
terle, 1 discredits this idea. It is found that certain houses and families 
exhibit repetitions of the disease suggesting localized infection. Even 
hereditary relationship could not be demonstrated, the children of 
goitrous parents being subject to the same circumstances of environ- 
ment as their elders. 

The only distinction between endemic cretins and other myxedemic 

patients is the goitrous enlarge- 
ment. This may be only a differ- 
ence of degree, because the cystic 
degeneration and interstitial hy- 
pertrophy at the bottom of the 
goitrous enlargement of the thy- 
roid is destructive in character 
and effect. It is easily conceiv- 
able that myxedema and mental 
disturbances will be developed 
proportionately to the lack of 
functionally active thyroid. When 
the thyroid is entirely wanting, as 
in the non-goitrous congenital 
cretin, or completely destroyed in 
some goitrous cretins, the myx- 
edema is correspondingly intense 
and the mental degeneration pro- 
portionately developed. It would 
seem, therefore, that the causes of 
endemic cretinism are those that 
._ produce endemic goitrous disease, 

Fig. 221.-Myxedematous cretin eighteen years old to which the Cretinoid State IS 

(Parker). secondary. 

Infantilism and Myxedema- 
tous Retardation. — Occupying a middle ground between myxedematous 
idiocy and acquired myxedema there are numerous cases showing slight 
cutaneous tumefaction, retarded mental development, and diminished 
growth. These patients retain their childishness both in mental at- 
tributes and physical conformation. Perhaps here belong some of the 




TROPHONEUROSES. 



519 



idiots classed as Mongolian by the English, and some of the enfants 
ariearre of the French. In at least one well-marked instance Brissaud 
found the thyroid body scarcely perceptible. At the age of ten numer- 
ous and large cervical glands had been removed, with probable resulting 
damage to the thyroid. Thereafter the physical, genital, and mental 
growth of the lad had remained stationary. Schmidt 1 has treated three 
cases of this sort in which growth was retarded by the administration 




Fig. 



222. — Myxedematous infantilism, 
nineteen years old (Brissaud). 



youth Fig. 223. — Cretinoid girl of sixteen years, 4 

feet tall, 65 pounds weight; thyroid not palpa- 
ble; milk teeth persistent; sella turcica enlarged; 
epiphyses ununited; mentally backward; sexu- 
ally infantile. 



of thyroids, with immediate improvement. In such mild cases of 
cretinism the pituitary gland is frequently enlarged and there is often 
a mingling of thyroidal deficiency and dyspituitary activity with poly- 
uria, excessive sugar tolerance, genital retardation, etc. 

Etiology. — If we look upon myxedema as the manifestation of 
defective thyroidation, its causes are those of disease or absence of the 



"Therapeutische Wochen.," Nov., 1896. 



520 



NEUROSES. 



thyroid body. In some cases it is a teratological defect; in others it is 
the result of a thyroiditis which may be dependent on infectious proc- 
esses, as the infectious fevers, rheumatism, etc.; in others it is cystic 
degeneration; in others the result of trauma or surgical extirpation. 
Taking all causes of myxedema together, there is a preponderance of 
females which reaches large proportions in the spontaneous adult varie- 
ties. It is probable that the close relation of the thyroid and uterine 
functions is at the bottom of this fact. It is only necessary to men- 
tion the increased size of the thyroid in pregnancy, its frequent enlarge- 
ment in pubescent girls, its usual congestion in some women during 
menstruation, and its final retraction at the menopause. Erysipelas of 




Fig. 223a. — Skiagram showing enlarged sella in case of Fig. 223. 



the neck and head and syphilis of the thyroid gland have induced 
myxedema. 

Regarding the manner in which defective thyroidation affects the 
trophic apparatus and induces the mucoid deposits, two general points 
of view depending upon opposite physiological hypotheses are main- 
tained. As yet all is theory. Many, with Scruff, believe that the nor- 
mal thyroid elaborates some substance indispensable to the proper 
action of the nervous system. This substance, however, has never been 
isolated nor its characteristics determined. Others, with Horsley, con- 
ceive that the thvroid transforms the mucinoid elements of the blood 



TROPHONEUROSES. 



521 



into utilizable metabolic constituents, or, as a modification of this idea, 
that the thyroid eliminates certain harmful elements from the blood. 
The blood in myxedema is poor in oxygen and the urine is of an 
increased toxicity. Both of these conditions are favorably modified, 
as is the myxedematous state, by the administration of thyroids. It 
now is determined that the thyroid gland is essential to life and to the 
proper neurotrophic balance. That it is essentially secretory is proved 
by its embryonal duct in man opening at the root of the tongue and 
its active connection with alimentary processes in the lower orders. 




Fig. 2236.— Skiagram of hands of Fig. 223. 



Morbid Anatomy. — The primal lesion of myxedema is located in 
the thyroid. In myxedematous idiocy the gland is either wanting, rudi- 
mentary, or atrophic. In acquired myxedema it is atrophic, yellowish 
white, and fibrous. At first there appears to be an embryonal vesicular 
infiltration, with epithelial proliferation. Later, fibrous changes pre- 
dominate, and finally complete sclerosis is presented. This practically 
constitutes a parenchymatous and interstitial thyroiditis. Murray, how- 
ever, believes that atrophy of glandular tissue is the first step, due 
probably to the action of some toxic agent, and that the increase of 
fibrous tissue is a replacement-fibrosis. The cystic degeneration of 
cretinoid goiter reaches the same results by its destructive action upon 
the glandular parenchyma. 

The subcutaneous cellular tissues are infiltrated with a gelatinous, 
mucinoid substance and the fatty paaniculus is much increased. Through- 



522 NEUROSES. 

out the organism there is a tendency to fibrous proliferation, which 
especially affects glandular organs, as those of the skin and the kidneys. 
Mucin has also been found in the blood and in all the tissues of the 
body. The pituitary gland and the thymus are frequently enlarged, 
apparently for the purpose of compensation. The nervous system pre- 
sents no changes that are uniform or significant. Central hyperemia 
and tumefaction of the nerve-cells have been noted by Rogowitch. 

Treatment. — The treatment of myxedema furnishes one of the 
most brilliant chapters in medicine. It was observed that in animals 
and man myxedema did not follow partial ablation of the thyroid, and 
Schiif found that a portion of the gland subcutaneously or intraperitoneally 
implanted prevented the myxedematous state in animals subsequently thy- 
roidectomized. Horsley suggested the same procedure in man, and it 
was carried into effect by Kocher, Lannelongue, Bircher, and others with 
favorable results. When the thyroid graft was successful, myxedema 
was temporarily checked. Murray first used subcutaneous injections of 
thyroid extracts or emulsions with better and more persistent results, and 
a series of cures were reported by this method in the hands of numerous 
observers. Howitz, of Copenhagen, followed shortly and independently 
by Mackenzie and Fox in England, and then by a host of physicians the 
world over, fed myxedemic patients with thyroids raw, partially cooked, 
or desiccated. The results were almost uniformly good. The pro- 
cedure is perfectly justified not only by clinical results, but by the fact 
that in lower animals and in the human embryo the thyroid gland fur- 
nishes a secretion to the alimentary canal by a duct opening at the fora- 
men cecum on the base of the tongue. The sheep's thyroid is habitually 
employed and is now an article of commerce in the form of various 
powders and tablets. The equivalent of one-half a sheep's thyroid may 
be administered daily, and if well tolerated, increased to a full thyroid or 
more. If prompt action is secured, it may be reduced, and if difficulties 
arise, it must be discontinued and resumed with caution. The exhibition 
of thyroids is followed in a day or two by a return of the temperature to 
the normal standard, which it may even exceed by a degree or two ; the 
pulse becomes more rapid, the urine increases in volume, the pigmentary 
infiltration diminishes, the fatty deposits melt away, and the patient 
becomes more animated and cheerful. Four to eight weeks may show 
a marvelous change. The skin becomes softened and moist, the hair 
and nails are better nourished, and the normal state of the patient is 
shortly attained. To maintain the cure, thyroid feeding must be main- 
tained. If the treatment is discontinued, the patient promptly relapses. 
The equivalent of one thyroid a week is usually sufficient for the pur- 
pose, and cases are now on record in which several years have been 
passed in apparent health and vigor under this regime. 

The treatment is attended by considerable danger, and in some in- 
stances it has been followed by fatal results. Headaches, pains in the 
bowels, diarrhea, neuralgia, insomnia, malaise, and nervous excitement 
are some of the unpleasant symptoms which should promptly lead to a 
reduction of the dose or to the temporary interruption of the treatment. 
Some of these disadvantages are attributable to improperly prepared 



TROPHONEUROSES. 523 

thyroids and ptomain poisoning. When the terminal cachexia of 
myxedema has appeared, this treatment is hazardous, but nothing 
else can possibly rescue the patient, and in some such cases it has done 
so. In children, especially in myxedematous idiots with rachitic de- 
formities, thyroids tend to produce a softening of the bones that may 
greatly exaggerate the osseous distortions. Parker 1 and others have 
met with this complication, and have recommended that such cases be 
treated in bed, and the weight kept off the legs. 

In acquired or operative myxedema thyroid feeding may be consid- 
ered established as a curative treatment. In cases of myxedematous 
retardation its results appear equally brilliant. In sporadic cretinism it 
is capable of producing the most marvelous improvement, which is com- 
plete in proportion as it is adopted early in life. In endemic cretinism 
its effects are beneficial, but as yet its proper value is not established. 

The action of thyroidin, a chemical compound isolated by Baumann, 2 
is practically the same as that of the various preparations of the gland, 
but is less likely to be attended by the accidents of ptomain poisoning. 
Against the tetany that sometimes follows removal of the thyroid, it is 
less efficient than the thyroids themselves. 

EXOPHTHALMIC GOITER. 

Exophthalmic goiter, otherwise known as Graves' disease, Base- 
dow's disease, cardiothyroid exophthalmos, and struma exophthalmica, 
presents, in most respects, a complete contrast to myxedema, but also 
shows some analogous features. We have considered myxedema as 
due to defective thyroidation, and we may, at least tentatively, look 
upon Graves' disease as the manifestation of excessive or perverted thy- 
roid activity, or of both. The disease is manifest by the three so-called 
cardinal symptoms of rapid heart, enlarged thyroid, and prominent eye- 
balls. To this must be added a fine tremor, mental irritability, and 
muscular weakness, which are equally common. Further, nearly every 
function of organic life may be disturbed. Flajani, in Italy, described 
the condition in 1802, and Parry, in England, in 1825. Graves taught 
it as a disease entity in 1835, and published it as such in 1843 ; mean- 
while Basedow, in Germany, had independently written of it in 1840. This 
serves to explain the various names applied to it in different countries. 

Etiology. — Graves' disease belongs to the reproductive period of life, 
being rare before puberty and after the menopause. Barret 3 was able 
to collect only 42 cases in children below the age of fifteen, the youngest 
being four and a half. In children the disease is more acute and rapid 
in its course and development than in adults. 4 It affects females five or 
six times as frequently as males. A neuropathic heredity is commonly 
encountered. Pubescence in girls, menstrual difficulties, chlorosis, and 
all debilitating conditions act as predisposants. In exceptional instances 
Graves' disease seems to be due to certain intranasal and intra-abdominal 
conditions. As exciting causes may be mentioned emotional and mental 

1 "Brit. Med. Jour.," July, 1896. 2 Notkin, "Wien. klin. Woch.," Oct. 22, 1896. 

3 "Jour, de Med.," July 10, 1902. 

4 Schkarine, "Gazette Medic." (Russian), 1908, Nos. 1 and 2. 



524 NEUROSES. 

shocks, especially profound and protracted anxiety and grief, but fre- 
quently cases attributed to such causes can be traced back of them. In 
such instances the mental strain may serve to precipitate the more promi- 
nent symptoms of the disease. Pregnancy may seem to excite the dis- 
ease. Occurring during its course, the disease is sometimes apparently 
modified for the better, but, on the other hand, may be aggravated. 
After delivery there is frequently distinct improvement. Graves' disease 
is often associated with other neuroses, such as chorea, hysteria, and 
epilepsy. It is observed sometimes with tabes, and the mental disturb- 
ance not infrequently reaches into the field of insanity. A family type l 
is sometimes encountered, affecting several or all offspring of parents 
who may show no abnormality. A special but rare association of 
Graves' disease is -with tetany, scleroderma, myxedema, and acromegaly, 
all of which are closely allied through relation to the thyroid body. 

Numerous theories as to its pathogenesis have been entertained. 
Graves considered it a disease of the heart. Marshall, Taylor, and Piorry 
attributed it to mechanical compression of the cervical vessels and nerves. 
After the experiments of Claude Bernard upon the cervical sympathetic, 
lesions of this portion of the nervous apparatus were believed to be at 
the bottom of exophthalmic goiter. Following Charcot, the disease was 
by many considered a pure neurosis similar to hysteria. At present there 
are two general theories in the field. One incriminates the medulla, 
the other, the thyroid. Pointing to the bulbar origin of the disease is 
the association of cardiac, vasomotor, secretory, and thermic disturb- 
ances, to which, in various rare cases, palsies of cranial nerves, pro- 
ducing ophthalmoplegia, facial palsy, trigeminal neuralgia, and auditory 
disturbance are added. In certain cases bulbar hemorrhage, atrophy of 
the restiform bodies, and degeneration of the solitary bundles have been 
found, and the association with tabes argues the same cause. Felehne and 
Dardufi, by experimental lesions of the restiform bodies, have produced 
the major symptoms of exophthalmic goiter. As a rule, however, the 
bulb is not structurally affected, and the diverse conditions cited are as 
likely to be effect as cause. 

Following Johnston there are many who believe that overactivity of 
the thyroid gland, causing a hyperthyroidation, explains the genesis of 
exophthalmic goiter. The principal facts supporting this point of view 
are : (1) The usual changes and enlargement of the thyroid ; (2) the im- 
provement and cures resulting upon removal of a portion of the gland ; 
(3) the symptoms of exophthalmic goiter induced by overdoses of thy- 
roids in myxedematous patients and normal individuals ; (4) the cases in 
which exophthalmic goiter has eventuated in myxedema through de- 
generative changes in the gland, and (5) the almost absolute contrast 
between myxedema and Graves' disease. 

Horsley, who has given most constant and careful attention to this 
subject for many years, and to whose investigation we owe much of our 
present knowledge regarding the functions of the thyroid body, insists 
upon the changes in the gland and its secretion. He declares that " ex- 
ophthalmic goiter in its various degrees results from perversion of the 
3 Brower, "Chicago Med. Rec," 1898; Holmes, 'Thila. Med. Jour.," June 11, 1898. 



TROPHONEUROSES. 525 

function of the thyroid gland." 1 It has been found by many observers 
that the use of thyroids in Graves' disease often intensifies all the symp- 
toms, but there are certain cases in which they seem to cause improve- 
ment. Is it not reasonable to suppose that when the gland is simply or 
mainly overacting their administration increases the hyperthyroidation, 
but may benefit the cases that by perversion of thyroid function are not 
supplied with a normal secretion? Cunningham, 2 on experimental 
grounds, reaches with Gley the conclusion that the majority of symptoms 
in Graves' disease may be plausibly explained by the hypothesis of 
deficient thyroid activity. This Kocher, on very logical grounds, entirely 
denies. 3 The question of the relation of thyroid action to the functions 
of the nervous system has been already outlined in the description of 
myxedema (see p. 520). 

Accepting the thyroid theory, we are still confronted with the initial 
question as to why the thyroid function is primarily disturbed. Some 
have attributed this to infection setting up a thyroiditis, and point to 
the frequent history of antecedent infectious fevers, etc. Others accuse 
the neuropathic heredity or constitution. The real cause still escapes 
us. The intimate relation of thyroid and uterine functions (see p. 520) 
and the usual occurrence of exophthalmic goiter during reproductive 
life are of interest. 

Morbid Anatomy. — The autopsical findings in exophthalmic goiter 
are inconstant and variable. The heart is often dilated ; the sometimes 
thickened walls may present fatty degeneration. The valves are dis- 
eased only as accidental concomitants. The thyroid body may present 
any goitrous variation from simple congestion to the most destructive 
lesions. Usually the lobes are unequally enlarged, firm to the touch, 
and present a reddish, pulpy aspect. Colloid degeneration in places is 
not uncommon and may result in cystic formation. The vessels are 
thickened, dilated, and, in chronic cases, atheromatous. There is a pro- 
liferation of connective tissue throughout the gland which may reach a 
sclerotic degree. The acini of the gland become dilated ; the colloid 
material disappears, leaving a granular debris ; the secretion becomes 
thin and watery, the epithelium more or less disintegrated. The thymus 
is often persistent and enlarged, showing increased vascularity and 
an attempt at compensatory or perhaps at antagonistic activity. Capelle 
found it enlarged in 80 per cent, of 60 fatal cases, and Ord and Mackenzie 
assert that it was enlarged in all cases examined by them. The orbital 
cavity is often normal, but as frequently presents some fatty proliferation, 
and almost always the evidence of a continuous retrobulbar congestion. 

On the part of the nervous system the alterations in the cervical sym- 
pathetic ganglia, described in early accounts, are not found. Changes 
attributable only to the cachectic state are detected. In the bulb and 
spinal cord vascular degeneration has been encountered, with occasional 
small hemorrhages and dilatations. Atrophy of the restiform bodies 
and of the solitary bundles has been noted once or twice, as has atrophy 

1 "Brit. Med. Jour.," Dec. 5, 1896. 2 "Jour, of Experimental Med.," 1898. 

3 "Brit. Med. Jour.," June 2, 1906. 



526 NEUROSES. 

of the ascending root of the trifacial. The associated lesions of tabes 
are more frequent. 

The muscles, according to Askanzy, 1 show fatty infiltration, usually 
distinct to the naked eye. The fat globules are seen microscopically in 
long rows in the muscle-fibers, which also show increased, sometimes 
degenerated nuclei. 

Symptoms. — The onset of exophthalmic goiter is frequently in- 
sidious, and the patient can scarcely say when it began. In other in- 
stances the major symptoms appear within a few days or even within 
a few hours, following some inciting shock, but it is always allowable 
to suppose that unobserved minor manifestations had been previously 
present. Such fact can frequently be elicited by judicious inquiry. 
Cardiac palpitation, nervousness, irritability, and unaccountable fatigue 
are often felt for months before the more prominent symptoms are declared. 

Cardiovascular Features. — The cardiac disturbance usually is the 
first of the triad of cardinal symptoms to appear. The pulse becomes 
rapid, and ordinarily reaches 120 a minute, unless the patient is 
reclining and at perfect rest, when it may drop to 90, but never reaches 
normal during the activity of the disease. A rate of 150 or even 200 
is not very rare. Of the three major symptoms a rapid pulse may 
alone exist, and, taken with several other and minor symptoms, may 
suffice for a diagnosis. It is the only essential symptom. Ordinarily 
regular, the rhythm of the heart-beat in some cases is greatly disturbed. 
The heart acts in the most tumultuous, irregular manner, and its in- 
competence is shown by vertigo, cyanosis, and precordial distress. Pal- 
pitation and cardiac throbbing are experienced by most patients, and 
may be occasioned by the slightest physical or mental distress. At such 
times the breast, neck, and face are frequently suffused, and hot waves, 
with violent blushes, may sweep over the upper part of the chest, neck, 
and face. At first, and sometimes throughout the disease, the stetho- 
- scope reveals nothing but the tachycardia and violent systole. Func- 
tional systolic bruits and anemic murmurs are not infrequent. Organic 
valvular disease is practically an accidental complication. An apparent 
hypertrophy is really due to dilatation and to the enlarged area over 
which the apex-beat extends by its increased violence. In late cachectic 
stages the dilatation, with degeneration in the heart-muscle, becomes 
physically apparent and threateningly prominent. Grocco 2 finds that 
dilatation is always present during attacks of tachycardia, that there is 
an intimate relation between the amount of dilatation and the general 
asthenia, and that intense but transitory changes in the sounds and shape 
of the heart are marked features of the disease. 

The entire circulatory system is affected. This is most manifest in 
the aortic branches, especially in the cervical arteries, and is seen in the 
temporal and retinal arteries and veins. It is less well marked in the 
extremities, but Gerhardt 3 has noted it in the palmar arches and in the 
crurals. He also calls attention to the presence of capillary pulsation 

1 "Deutsch. Arch. f. klin. Med.," Band 61. 

2 "Riv. crit. di Clin. Med.," Jan. 2, 1902. 

8 "Centralblatt f. Chirurgie," Sept. 5, 1896. 



TROPHONEUROSES. 527 

in the spleen and liver and kidneys. In cases of long standing, vascular 
dilatation is produced and the veins themselves become fibrous and 
arterialized. The blood shows mainly the alterations of a simple anemia, 
but without increase of the total number of white cells the lymphocytes 
frequently are increased even to 60 or 70 per cent., and 30 per cent, is 
very common (Kocher). 

The goiter may appear at any period of the disease or may never 
develop. In some instances it is of insidious growth, and the patient's 
attention is only incidentally called to it by tightness of the ordinary 
neckwear. In other instances it is of sudden development, or may ad- 
vance in size at intervals, or advance and recede repeatedly. In any 
case it rarely attains very large proportions, and practically never inter, 
feres mechanically with respiration. It is usually asymmetrical, the right 
lobe commonly being most affected. The swelling may be confined to 
one lobe, usually the right, or it may involve the isthmus alone. The 
tumor usually offers considerable resistance to palpation, and a pulsatile 
thrill is frequently to be detected. In some instances nodules, indic- 
ative of parenchymatous changes^ can be made out. Auscultation over 
the enlarged thyroid readily detects in most cases a 
bruit synchronous with the pulse, and the tumor can 
often be seen to expand with every systolic impulse. 
By manual compression it may often be greatly re- 
duced in size for the moment, and it has a tendency 
to fluctuate in volume during the progress of the dis- 
ease, increasing in size upon the occasion of any 
physical or mental excitement. In late cases, through 
interstitial thickening or cystic degeneration, it may 
give a sclerous or fluctuant feeling to the touch, and 
does not then recede upon the cessation of the malady. 
It may even become markedly atrophic, and then 
myxedema gradually develops. Fig 223c _ Fades to 

Ocular Conditions. — With the appearance of Graves' disease. 

exophthalmos, which usually promptly follows the 
goitrous enlargement, the famous triad of symptoms is complete. It 
may appear before the goiter or in cases that never show thyroid enlarge- 
ment. Both eyes commonly are affected, but at first usually in unequal 
degree, and exceptionally but one is prominent. This occurs usually in 
cases in which only one lobe of the thyroid is enlarged, and commonly 
on the same side. 1 The prominent eyeballs with wide-open lids give 
an expression of excited fierceness aud fright strangely mingled, and 
quite disconcerting to strangers. The ocular protrusion varies greatly 
in amount in different patients, but in extreme cases has caused actual 
dislocation of the eyeball. Unless it exceed a moderate amount it occa- 
sions no inconvenience and may even escape the patient's attention. In 
a more pronounced degree the exophthalmos induces some difficulty in 
ocular movements and causes ocular fatigue. When exophthalmos is 
well marked, a distinct bruit has been heard by placing a stethoscope on 
the closed lids. 2 The cornea may also become inflamed from inade- 

1 Fridenberg, "Med. Record," July 13, 1895. 

2 Sanger Brown, personal communication. 




528 



NEUROSES. 




quate protection, especially at night and in the wind. There is fre- 
quently an increased lacrimation, which may occur independently of 
the exophthalmos, and later the secretion of tears may be defective. 
Conjunctivitis and keratitis may arise as complications, and perforation 
by ulceration has been known. 

The lids are usually retracted and often show peculiar and important 
motor difficulties. Winking is infrequent, but in occasional instances is 
rapidly repeated at momentary intervals. Von Graefe noted that in 
looking down the upper lid did not correspondingly follow the move- 
ment of the ball as in health. This sign is not related to the amount of 
exophthalmos, as it is sometimes found in normal individuals, and may 

be absent in marked cases 
i 2 of Graves' disease. Stellwag 

called attention to the usual 
widening of the palpebral fis- 
sure and the incomplete closure 
of the lids even when the pa- 
tient thinks the eyes are firmly 
closed. In a few cases Joffroy 
has noted a similar inactivity 
of the lower lid and of the 
frontalis in looking upward, 

L| voluntary control of the latter 
\ . | muscle remaining perfect. The 

outline of the palpebral fissure 
is often more or less angular, 
losing its smooth curves. 
Mobius has called attention to 
a difficulty of convergence that is commonly present. Kocher 1 considers 
a sudden retraction of the upper lid when the patient is directed to look 
steadily at the examiner or upward a very early and persistent symptom. 
In exceptional cases an external ophthalmoplegia has been seen. Paresis 
of the frontalis or of the entire facial nerve or involvement of the sensory 
and motor portions of the trifacial has been noted. Pigmentation of the 
lids is often excessive. 2 

Vision is usually intact and the pupils are generally normal, but 
myopia may develop on extreme pressure from exophthalmos. Accord- 
ing to Sainton and Rathery, 3 the pupils may be affected in four ways : 
(1) dilatation, which is relatively common ; (2) contraction, which is less 
frequent ; (3) inequalities, which are rare ; and (4) dilatation, later 
changing to contraction, which is extremely uncommon. The eye- 
grounds show no abnormality aside from retinal congestion and dilated, 
sometimes pulsating, vessels. Photophobia and brilliant muscse are 
attributable to the retinal congestion, and hallucinations of sight may 
have the same origin. 

Motor Conditions. — Besides the motor disturbances of the eye and 
its appendages, previously indicated, the entire musculature is affected 

1 "Brit. Med. Jour.," June 2, 1906. 2 Jellinek, "Wiener klin. Woch.," 1904, Nr. 43. 

3 "L'Encephale," 1908, No. 7. 



Fig. 224.— Exophthalmic goiter: 1, Shows exoph- 
thalmos and the thyroid tumor ; 2, the peculiar out- 
line of the palpebral opening and the failure of the 
brows and lower lids to ascend in looking upward. 



TROPHONEUROSES. 52£ 

with such marked weakness that Charcot was led to describe a Base- 
dowian paraplegia. Muscular asthenia is often an early symptom. The 
reflexes may be diminished and the legs may suddenly give way, causing 
the patients to fall heavily. Of similar origin are the shallow respiratory 
excursions and diminished expansion of the chest. Cramps, contractures, 
fleeting tetanoid conditions, and even epileptiform crises have been 
noted. The occasional association of chorea, epilepsy, and hysteria has 
already been mentioned, and must not be confounded with motor dis- 
turbances due to Graves' disease. Tetany has been seen by the writer 
in one case in the terminal period of the disease. 

An almost constant symptom in Graves' disease is a fine tremor which 
is as significant as any one of the cardinal triad. It is of variable 
intensity, may appear only at intervals, and be limited to the head and 
upper extremities. By placing the finger-tips on the head when the 
patient is sitting or standing, the examiner will be aware of a vibration, 
and this may be demonstrated by placing a long feather in the patient's 
hat. It usually is easily seen in the extended hands, especially if the 
fingers be spread widely, or it may be then felt by grasping the patient's 
wrist. In some cases the entire trunk is affected, and in standing, the 
tremor may be present in the lower extremities. It is sometimes dis- 
tressing to the patient, but often occasions no complaint, and must be 
intelligently sought. The rapidity of the tremor is from eight to ten 
oscillations a second. 

Secretory and Vasomotor Features. — With the hot waves and 
morbid blushing that have already been noted there is often profuse 
perspiration, which may be widely distributed, limited to one side of the 
body, or most abundant on the hands and feet. In some cases it necessi- 
tates frequent changes of underclothing. Usually it is attended by a 
feeling of almost unbearable heat, and these patients often seek cool 
rooms even in winter and find all bed-covering intolerable. The bodily 
temperature may be quite normal, but in rare instances an elevation of 
from one to five degrees has been noted, and in the terminal cachexia of 
fatal cases hyperpyrexia is commonly encountered. Hemorrhages from 
the uterus, nose, gums, and lips are not infrequent. x Polyuria, especially 
periodical polyuria, is a common phenomenon, and glycosuria is sometimes 
encountered. Albuminuria, however, is the rule at some period of the 
disease. It is usually intermittent and appears when the other manifes- 
tations of the disease are exaggerated, as if due to the hypervascularity 
of the medulla. Edema is common, but peculiar and usually circum- 
scribed ; it may affect the upper eyelids and has a preference for the 
outer aspect of the legs, the thighs, and the abdomen. The infiltration 
is not boggy and does not pit on pressure, but reminds one of the resi? 
liency of myxedematous swelling. In rare instances it may become 
generalized and does so in those cases that eventually develop myxedema. 

Mental Disturbances. — From the beginning, and often for a long 

period antecedent to the appearance of cardiac symptoms, the subjects 

of Graves' disease present a considerable mental erethism. There is an 

indefinable and tormenting agitation, marked by mental and motor 

1 S. Popoff, "Neurol. Centralbl.," April, 1900. 
34 



530 NEUROSES. 

restlessness and an imperative and impulsive tendency to be doing. 
Their emotions are too readily excited, and they are unusually impres- 
sionable and irritable, reacting in an exaggerated manner to all the inci- 
dents of daily life. In more pronounced cases they become voluble 
and manifest the greatest mobility of ideas, without persistent concen- 
tration or logical order. Their affections are likely to undergo modifi- 
cations, and they become irascible, fault-finding, inconsiderate, ungrate- 
ful, and hard to live with. In some instances this disturbance of 
mentation carries them over the border into active mania, marked, 
perchance, by delusions of fear, due to the cardiac symptoms or the 
sensations of heat. Insomnia is often added, and the fitful sleep is 
disturbed by horrifying dreams that are likely to be projected into the 
waking moments and woven into delusions which are usually unsys- 
tematized, and constantly changing, furnishing the analogue of the motor 
restlessness. Hallucinations of sight and hearing are not uncommon. 

The mental perturbation only rarely reaches the degree of actual 
mania, and then is, perhaps, equally dependent upon numerous other 
causes acting in a neurotic individual. But a condition of abnormal 
mental stimulation is characteristic of the malady, and as important an 
index as any of the cardinal triad. 

The skin is often marked by abnormal pigmentation, which may be 
distributed in irregular plaques over the body, face, and limbs, or in 
rare instances produces zebra-like markings on the trunk. In certain 
cases it much resembles the bronzing of Addison 7 s disease, but usually 
spares the mucous surfaces, though not always. Vitiligo, scleroderma, 
and various cutaneous eruptions are sometimes encountered, and the 
hair may become thin. The sensation of heat is usually associated with 
a diminished resistance to electricity, which may be reduced to a third or a 
fifth of the normal. This is possibly related to the excessive perspiration, 
but does not obtain in other diseases in which sweating is equally great. 

Digestive disturbances are numerous and not marked by anatomical 
lesions. Anorexia, voracious appetite, vomiting, diarrhea, dysentery, 
and icterus may be encountered in different patients, or many of them 
at various times in the same patient. The diarrheas are particularly 
important, as they rapidly reduce the patient's strength and tend to 
hasten the appearance of cachexia and a fatal termination by exhaus- 
tion. The frequent painless stools are made up of undigested food 
and an abundance of watery mucus, sometimes liberally streaked 
with blood. The defects in nutrition are always pronounced and a 
loss of weight from the first is the almost exceptionless rule. It 
may occur intermittently, the patient losing eight or ten pounds in 
a week and gradually regaining it. Huchard 1 is inclined to look 
upon such loss of weight, and especially upon its intermittent occur- 
rence, as of diagnostic importance. It may occur independently of the 
diarrhea, sweating, polyuria, or any other physical drain, and in the face 
of an active bulimia. 

Respiratory disturbances are not uncommon. They are frequently 
secondary to the cardiac disorder. Dyspnea, asthmatic attacks, pul- 
1 "Jour, de Med.," Feb. 10, 1896. 



TROPHONEUROSES. 531 

monary congestions, bronchitis, and a persistent cough, without stetho- 
scopic symptoms, may be presented. The dyspnea is the same as 
that in myxedema, and appears to be due to the athyroidal condition 
(Horsley). Shallowness of respiration and inefficient thoracic expan- 
sion are related and proportionate to the muscular asthenia. 

The genital functions are usually modified. Increased sexual appe- 
tite has been noted in men and women in the early periods of the 
disease. Later, as general asthenia develops, it is correspondingly re- 
duced. Amenorrhea is present, or the tendency is well marked, and 
leukorrheas are abundant. 

The following table of symptoms and their relative frequency is 
based on Paessler^s statistics, 1 comprising fifty-eight cases, of which 
forty-two were women. It must be borne in mind that nearly all the 
symptoms of Graves' disease are intermittent, and any tabulation, to be 
satisfactory, should cover the entire course of the disease and embrace 
a very large number of cases : 

Table showing Relative Frequency of Symptoms in Graves' Disease, 
Based on Fifty-eight Observations. 

Neuropathic family history 29 Sensations of warmth 24 

Tachycardia 57 Vertigo 23 

Nervous irritability and restlessness . 57 Insomnia 21 

Characteristic tremor 52 Stellwag's symptom 20 

Palpitation and vascular disturb- Tachycardia, goiter, exophthalmos, 

ances 50 and tremor combined 18 

Goiter 48 Polydipsia . . . . . • 17 

Increased perspiration 34 Cardiac dilatation 15 

Anemia 34 Irritable cough «... 10 

Severe headaches 32 Graefe's symptom 9 

Exophthalmos 28 Mbbius' symptom 9 

Severe diarrhea 26 Valvular heart disease 5 

Course and Progress. — The great diversity encountered among cases 
of Graves' disease makes it difficult to outline its clinical course. It 
may be of apparently sudden or of insidious onset, and may show any 
combination of the long list of symptoms that have been detailed above. 
It may run its course to a favorable termination in three months or may 
take six years, or continue throughout or terminate life. The great major- 
ity of cases are of protracted duration. Early recoveries and fatalities are 
alike exceptional, and when all other symptoms have subsided, promi- 
nent eyes and a moderate goiter may remain to mark the passage of the 
disease. The appearance of active diarrhea, of polyuria, intense albumin- 
uria, and rapid wasting darkens the prognosis. Extreme asystole, great 
cardiac dilatation, and a failing circulation have the same import. 
Maniacal disturbance is not of itself of bad prognosis, which depends 
rather on failing bodily conditions. The cardiac symptoms are usually 
the first to appear, and afford the best criterion as to the progress of the 
disease. Their improvement is the only unqualified sign of gain. A 
state of nervous susceptibility is usually left after recovery that may be 
compromised by the slightest shock. 

Diagnosis. — In the presence of the Basedowian triad diagnosis can 
1 "Deut. Zeit. f. Nervenheilk.," Bd. vi, S. 21. 



532 NEUROSES. 

not fail, but in the abortive forms it requires a careful and thorough 
investigation and an experienced judgment to recognize the disease. 
Tachycardia, with irritability, sweats, insomnia, emaciation, and perhaps 
a slight rise in temperature may mimic phthisis very closely, and if an 
irritable cough is added, the mask is almost impenetrable, especially as 
some pulmonary dullness, due to the congestive condition, may be 
present. The mental attitude is of some assistance, and should the 
tremor be observed or some slight thyroid turgescence be made out, the 
diagnosis may be effected. Some of these formes frustes are put down 
as neurasthenia, in view of the asthenic condition so commonly present. 
It requires the presence of eye, thyroid, cardiac, or tremor symptoms 
to make the diagnosis positive. Every case of Graves' disease is at the 
same time myasthenic, and may also be neurasthenic. 

Treatment. — In the management of this disease, whatever line of 
treatment may be added, it is of the utmost importance to secure rest and 
quiet. With complete rest, as by the Weir Mitchell course, some cases 




Fig. 225.— Partial recovery. Some exophthalmos, pigmentation of skin, and goitrous thickening remain. 

make immediate and substantial progress. If this is not available, it 
should be approached as nearly as the circumstances of the patient 
permit. In the asthenic, irritable state, a conservation of energy is 
strongly indicated. Digitalis, strophanthus, and strychnin have a favor- 
able action on the heart in some cases, and strychnin in full doses is 
occasionally of benefit to the general nervous condition. Sedatives such 
as bromids and belladonna have not yielded the writer good results in 
any instance, but chloral is often valuable for the insomnia. Iron must 
be used with caution even to combat the anemia so commonly present, 
as it frequently disturbs the intestinal tract and augments the vascular 
storms. Hydrotherapy and massage are of benefit in some cases. Elec- 
tricity locally has strong advocates, some favoring faradism, others gal- 
vanism. A moderate faradic current through the root of the neck, 
causing all the anterior cervical muscles to contract about the thyroid, 
mechanically diminishes it in size. This may last a few minutes or 
for a few hours after the current is stopped if the patient is not excited 



TROPHONEUROSES, 533 

in any way. An uninterrupted galvanic current may produce a similar 
result, and passed through the temples occasionally causes a recession 
of the eyeballs, but the effect is very fleeting and does not influence the 
tachycardia. Electricity should be used daily, or several times a day. 
Mechanical compression of the thyroid by bandaging is insupportable. 

Injections of cicatrizing agents, such as tincture of iodin, into the 
substance of the gland, at one time much in vogue, are now generally 
abandoned, as they are of doubtful value and are attended by consider- 
able danger to life. Injections of boiling water have been used with 
alleged immediate improvement, but all such measures must be inexact, 
as they depend upon local necrosis for their effect. In long-standing 
cases ablation of a portion of the gland has produced good results in 
the hands of various operators, but it has a considerable mortality — 
about 12 per cent. Schulz 1 reports 14 cases with 12 cures, but 
Sanger 2 cites a case in which all symptoms were aggravated. Cystic 
portions may be removed, but caution must be exercised to leave a 
fair amount of normal gland. The same effect is obtained by exposing 
the gland by a median incision and securing it in the wound (the exothy- 
ropexy of Jaboulay), but even this comparatively simple operation has 
been followed by death. Thus operated, the thyroid shrinks in size 
and the symptoms decrease. The wound is closed at a subsequent 
period. Surgeons are meeting with better results from partial thy- 
roidectomy, especially in the less advanced cases, now that the para- 
thyroids have been recognized. When they can be isolated and spared, 
the operation is much less objectionable. It must receive careful con- 
sideration in every case. The mortality is still considerable. Tabu- 
lated results show this to be about 10.5 per cent. Thus: Moses, 3.6 
per cent.; Starr, 12.1 per cent.; Kinnicut, 3.9 per cent.; Rehn, 13.1 
per cent.; Lorgo, 13.9 per cent. In the hands of Mayo and Kocher the 
mortality has gone down to less than 5 per cent. Jonnesco 3 and others 
have claimed improvement from bilateral ablation of the cervical sym- 
pathetic. The operation is a serious one, not without bad results, 4 
and should be condemned. The detection of an enlarged thymus gland 
makes prominent the probability of serious or fatal conditions arising 
under surgical proceeding. 

Thyroids have been used. Ordinarily, they intensify the symp- 
toms. In a minority of instances the goiter is reduced in size quite 
promptly, but the pulse is usually not improved, and the nervousness 
and tremor are generally accentuated. They may be carefully tried 
experimentally. A number of cases have been benefited by the use of 
thymus feeding. Owen 5 has collected about 20 cases in which its 
effect was mainly beneficial. Mackenzie, 6 in an equal number of cases, 
found it of little or no value. Owen called attention to the probable 
physiological antagonism between thymus and thyroid action. The 
persistence or reappearance of the thymus in these cases, often noted, 
among others by Hektoen, 7 may have the same significance. Some 
encouraging results have been obtained by feeding patients on the milk 

1 ''Berliner Klinik," June, 1897. 2 "Munch, med. Wochens.," April 6, 1897. 

3 "Centralbl. f. Chir.," Jan. 16, 1897. 4 Aschard, "Rev. de Neurol.," Aug., 1900. 
5 "British Med. Jour.," Oct. 10, 1896. 6 "American Journal," Feb., 1897. 
7 "International Med. Mag.," Sept., 1895. 



534 



NEUROSES. 



of thyroidectomized goats or using a serum obtained from the blood of 
thyroidectomized animals. Several hemic products from such animals 
are being put upon the market, but their value is as yet undetermined. 
Ovarian preparations and adrenalin have also been used with uncertain 
and unreliable effects. 

The numerous complications must be met as they arise. Atropin for 
the sweats, bismuth and opium for the diarrhea, careful dieting for the 
gastric and intestinal troubles and a general tonic and upbuilding 
regime. Thompson, of New York, insists on a milk diet. 



SCLERODERMA. 

Scleroderma is a trophoneurosis presenting an induration and atrophy 
of the skin, or atrophy without preceding induration. It occurs (1) in 
a generalized form, but affecting the extremities and face principally, 

and (2) in a circumscribed form, marked by 
isolated plaques and stripes. These may be 
confined to one side or be roughly sym- 
metrical in distribution, and are often limited 
to the cutaneous extent of certain nerve- 
trunks or branches. This has led Jonathan 
Hutchinson 1 to use the term herpetiform 
morphea. The disease is also known as the 
hide-bound disease, scleroma adultorum, 
sclerosis, chorionitis, morphea, and Addison's 
keloid. When the fingers are affected, the 
French employ the term sclerodactylia It 
is a rare disease, but not so uncommon as 
most writers insist, and if generally recognized 
would soon present a generous material. 

Etiology. — The female sex furnishes 
about three-fourths of all cases. Generalized 
scleroderma is most common in adults, but 
may be encountered between ten and twenty 
years of age, and the discrete form begins 
perhaps more commonly before twenty-five 
than later in life. It has been attributed 
to various infectious fevers, to traumatism, 
exposure to cold, rheumatism, and to pretty 
much every incident of human life. It 
probably has a relation to disease of the 
ductless glands, and particularly to disorder 
of the thyroid. A neuropathic constitution 
is of such striking frequency in these cases 
that it cannot be overlooked. Spinal cord 
and cerebral lesions are sometimes associated, and in the generalized form 
Raynaud's disease is a frequent concomitant. I have seen it associated 
1 "Brit. Med. Jour.," June 1, 1895. 




Fig. 226. —Generalized sclero- 
derma, showing facies, sclerodacty- 
lia and hide-bound state (Grasset). 



TROPHONEUROSES* 535 

with a progressive myopathy. Insanity is sometimes present, especially 
melancholia. 

Symptoms. — In the generalized form of scleroderma at first there 
is irritation followed by induration and thickening that may be red and 
suffused by vascular stasis and present blebs and bullae. Factitious 
urticaria and dermographia are commonly easily demonstrated. 1 On 
the broad surfaces of the trunk the skin feels stiffened and brawny. 
It is found to be bound down to the underlying parts, giving rise to the 
hide-bound descriptive title. Atrophy occurs later. All the dermal 
structures become thinned and present a cicatricial appearance, and may 
be glistening white. The hands and face are especially affected. The 
fingers are reduced to their slightest proportions, and the bones, covered 
by the atrophic, glistening skin, which fixes the joints and hmits motion, 
are lessened in size. Raynaud's disorder is often present. Over the 
facial bones the parchment-like integuments are tightly drawn in a 
motionless, unwrinkled mask. The thinned lids can scarcely be closed 
over the sunken eyeballs,, which consequently appear unduly large. The 
nose is thin and looks ready to split its way through the skin. The lips 
are papery and often retracted, exposing the teeth. The shortening of 
the skin from the jaw to the clavicles may even interfere with movement 
and with deglutition. Every bony prominence, as about the orbits, 
cheeks, and chin, is sharply defined. The epithelial structures are 
everywhere reduced, and nails and hairs are of defective growth. 
Sensibility is not much disturbed, as a rule, but hyper sensitiveness may 
be encountered. 

In the discrete form a local thickening may gradually invade the 
surrounding parts, but is limited by rather sharp borders and may be 
attended by herpetic eruptions. Later it becomes atrophic. In other 
cases a white atrophic spot appears and gradually extends over the 
course of the supplying nerve. It may thus produce zoster-like 
bands on the trunk and stripes down the limbs. The most common 
locations are the face, chest, and lower extremities. The outlines of 
these morpheic tracts and plaques sometimes forcibly remind one of the 
cutaneous areas of the spinal segments. 

Up to the time atrophic changes occur, the disease may recede and 
the normal condition be spontaneously established. Several years are 
usually consumed in the development of the disease. 

Anatomically, the disease is marked by a fibrosis attended or preceded 
by vascular changes. The nerves and all structures within the atrophic 
area equally show the fibrous proliferation. 

Treatment. — Tonics, electricity, hydrotherapy, massage, and gen- 
eral reconstructive measures have been found of some benefit in a few 
cases. Of late, Lustgarten, Sachs, Brain well, and others have reported 
great benefit from thyroid feeding, which, even in advanced cases, caused 
immediate and gratifvino; changes for the better. In recent cases it 
appears likely to produce a cure. Whether a relapse will follow dis- 
continuance of the remedy is not now certain. 

1 Launois, " Xouv. Icon, de la Salpet.," 1900. 



536 NEUROSES. 

TETANY. 

Tetany, or Manilla, is marked by peculiar tonic, bilateral, parox- 
ysmal, muscular contractions, commencing in and usually confined to 
the extremities, and presents an increased mechanical and electrical 
excitability of the nerves. It may occur in epidemics, is endemic in 
many places, and commonly develops on a background of malnutrition. 

Etiology. — It occurs most frequently before twenty and practically 
never after fifty years of age. Both sexes are affected, males more fre- 
quently before adult life, females more commonly thereafter. In Paris, 
Berlin, Prague, Vienna, and in Syria it may be considered endemic, and 
epidemics of it have been noted in these places, and in schools and garri- 
sons. In the neurological clinics of Berlin 1 tetany furnishes one per 
cent, of all cases. In Vienna seven-tenths of one per cent. It appears 
most commonly from January to May. In America it is comparatively 
rare outside of quarters in large cities largely populated by foreigners. 
Predisposing causes include nearly every variety of depraved nutrition. 
Sarbo, 2 from an extensive review of the causes of tetany, asserts that 
impaired nutrition is the only common factor. Of most importance are 
chronic gastro-intestinal disorders, especially gastric dilatation, with 
hyperacidity, fermentative diarrhea, and chronic constipation. Rickets 
is a very common accompaniment in children. Cassel 3 found it in 58 
out of 60 cases. Tetany may follow acute infectious and septic pro- 
cesses, or appear during pregnancy or lactation. Enucleation of the thy- 
roid has been followed by tetany in a considerable proportion of cases. 
Billroth and Wolfler reported 19 cases of tetany in a total of 123 thy- 
roidectomies. There is a certain relation between tetany and myxedema, 
which may concur in a given case. If about one-fifth of the thyroid is 
spared, tetany does not appear, according to von Eiselberg. Murray in- 
sists that it does not occur if the parathyroid is spared. As exciting causes 
of the paroxysmal attacks, exposure to cold and emotional disturbances 
are often active, as are overexertion, exhaustion, acute diarrhea, and 
vomiting. The administration of ergot, chloroform, and alcohol has 
caused them to appear, and they may be induced by mechanical irritation 
of the nerve-trunks and blood-vessels, in the manner to be described later. 

The epidemic, endemic, seasonal, remissive, and toxic features of the 
disease point very strongly to the activity of some zymotic agent, but as 
yet it has escaped detection. Oddo 4 suggests that it may only be active 
in the presence of some special form of perverted digestion. The vul- 
nerable portion of the nervous system appears to be the spinal and bul- 
bar gray and the peripheral nerves. The relation of the parathyroid 
bodies to the tetany of operative myxedema and that of parathyroid- 
ectomized animals points to the probable participation of these glands in 
the development of ordinary tetany. The parathyroid bodies have 
been found variously diseased in many cases of tetany. Beside chrom- 
aphilic and cytological abnormalities, hemorrhages, cysts, leukemic 
infiltration, tuberculosis, bacterial emboli, and adenomatous changes 

1 Lathrop, "Boston Med. and Surg. Jour.," Nov. 19, 1896. 

2 "Deut. Zeit. f. Nervenheilk.," 1896. 3 "Deut. med. Wochen.," Jan. 28, 1897. 
4 "Munch, med. Wochen.," Nov. 10, 1896. 



TROPHONEUROSES. 537 

have been seen (Erdheim). Yanase found hemorrhages in 33 out of 89 
cases in children. 1 McCallum and Yoegtlin 2 have demonstrated that 
the parathyroids practically control the calcium metabolism of the body 
and that ablation of the parathyroids is followed by a reduction of 
calcium salts in the blood, and that the administration of calcium salts 
prevents or reduces the tetany. It is noticeable that conditions requir- 
ing calcium metabolism are usually associated with the tetany. Thus 
dentition, rachitis, pregnancy, lactation, and protracted digestive dis- 
orders are the common concomitants. Hence the value of a milk diet 
which is rich in calcium in these cases. Morbid anatomical changes in 
the nervous system are not constant, though suggestive. Cloudiness and 
swellings in the anterior horns have been noted by TViess and by Barome 
and Cervasato. Peters, 3 in a recent communication, claims to have 
found in 7 cases an acute inflammation of the extradural connective 
tissue among the extradural blood-vessels and fat, constituting a pachy- 
meningitis externa and secondarily inducing a root neuritis and gan- 
glionitis proportionate to the clinical manifestations of the disease. 

Symptoms. — The clinical manifestations mainly fall within the doT 
main of the motor neurons. The first thing to attract attention is the 
development of spasmodic stiffness, usually first appearing in the fin- 
gers and wrists. After the recurrence of several attacks adults sometimes 
recognize in malaise, headache, depression, and general pains, premonitions 
of the on-coming rigidities, The attacks are initiated by a feeling of 
prickling, nurhbness, and some local 
pain. The spasm comes on slowly and 
increases gradually in intensity, accom- 
panied by growing discomfort and pain 
in the muscles. There are no mental 
features attributable to tetany. The 
spasms begin peripherally in the fingers 
and toes, and advance toward the trunk. 
Ordinarily, they are limited to the 
limbs, and mainly affect the parts be- ^ 

low the elbows and knees. The upper 
extremities may alone be invaded. In 
other cases the tonic spasm reaches the 
roots of the limbs and invades the 
trunk, and may involve all the body- 
muscles in very severe cases. Retrac- 
tion of the head and strabismus are ""^ 
seldom encountered. The contraction 
is tonic in character and usually per- 

sktpnt dnrino- thp attaok but* rnnv Fi §- 227.— Infant with mild attack of 

MbieLLl UUIlIlg Lite dttdLK, UUl Hid,) tetanT) showing characteristic spasmodic 

intermit. The attack may last from a position of hands and feet. 

few minutes to many hours and occur 

several or many times daily. Attacks may cease for intervals of days, 

1 "Jahrb. f. Kinderheilk.," 1907. 

2 "Johns Hopkins Hosp. Bull.," March, 1908. 

3 "Deutsch. Arch, fur klin. Med./' vol. lxxvii. 




538 NEUROSES. 

weeks, or months, and then reappear, but if latent they can be provoked 
in the intervals by appropriate manipulation. 

The positions and attitudes caused by the spasms of tetany are 
strikingly peculiar. Ordinarily, the hands are rolled into the cone-shape 
of the accoucheur, the digits flexed at the metacarpal joints and rigidly 
extended at the internodal articulations, the thenar and hypothenar 
eminences approximated. The wrist may also be flexed and the hand 
drawn to the ulnar side. Less commonly the fingers and wrists are 
extended, or the hand may be made into a fist grasping the thumb, or 
the thumb may protrude between the index or middle digits. In cases 
of severity the elbows are flexed and adducted strongly against the body. 
The feet, when affected, present a forced equino varus position, with flexed 
and sometimes overlapping toes. In extreme cases there is flexion at 
the knees and hips. The muscles of the forearms, legs, hands, and feet 
are tense, firm, and often sensitive. Voluntary movements in the parts 
are impossible, and passive motion causes pain. When the spasm in- 
vades the trunk, intercostal, abdominal, and spinal rigidity may appear 
and breathing be impeded. In rickety children laryngismus stridulus is 
not uncommon ; in adults laryngeal spasm constitutes a serious compli- 
cation. In rare instances spasm in the neck-muscles draws down the 
chin and the angles of the mouth, and has even produced fatal com- 
pression of the air-passages. Solovieff 1 has noticed in adults rhythmic 
contractions of the diaphragm synchronous with the heart-beat and 
attended by a whistling sound in the left lung. Thoracic and diaphrag- 
matic rigidity may induce asphyxia and even death. Ordinarily, the 
face escapes. The sphincters may be tonically contracted, inducing 
obstipation and anasarca, according to Oddo and Sarles, 2 who also noted 
indican in the urine, due to intestinal fermentation, and confirmed 
Weiss' observations of the hypertoxicity of the urine. Retention of 
urine may be the most prominent symptom. 3 

The electrical and mechanical irritability of the motor nerves is 
peculiarly increased. If pressure be made over the median or ulnar 
nerves, the spasm in the hand is increased, or during its absence is pro- 
voked. Pressure over the brachial artery may have the same effect. 
This is known as Trousseau' 's sign, and is practically pathognomonic. 
Gentle tapping on the nerves, as with a percussion hammer, has the 
same effect. Chvostek discovered that the facial nerve could be aroused 
in the same manner, causing a facial contortion exactly limited to the 
distribution of a branch or of the entire nerve, depending upon the loca- 
tion of the blows — Chvostek? s sign. Erb first described a peculiar exal- 
tation of the electical excitability, especially to the galvanic current — Erb's 
phenomenon. A single cell, giving but one or two milliamperes of cur- 
rent, may be sufficient to provoke sharp contractions, and anodal opening 
tetanus (A. O. Te.) is found in this disease alone. Sarbo has, in a single 
case, noted the myotonic reaction in the triceps, a response that was con- 
sidered confined to Thomsen's disease. It consists of persistent contrac- 
tion, lasting some moments after cessation of the galvanic current. The 

1 " Rousski Vratch," 1902. 2 " La Med. Inf.," Sept. 15, 1894. 

3 Burkhardt, " Jahrsb. f. Kinderh. " 1899. 



TROPHONEUROSES. 539 

faradic responses are also accentuated in most cases, but many remain 
about normal. Pressure upon the nerves is more than ordinarily pain- 
ful, and readily induces persistent paresthesia in their cutaneous distri- 
bution. The tapping that causes spasm also induces pain. Schlesinger l 
has directed attention to a leg sign which he ranks with the Trousseau 
phenomenon. If the extended lower extremity during the intervals be- 
tween spasms is strongly abducted at the hip, in a few moments a pain- 
ful cramp develops in the knee and a tonic cramp appears in the foot 
and toes. Edema of the hands and feet and localized perspiration may 
be encountered. The temperature may be normal, but is often elevated, 
as might be expected, in the gastro-intestinal cases, and subnormal in 
the athyroidal state of operative myxedema. Auditory and optic 
symptoms and trophic changes in the muscles are found only as acci- 
dents. Objectively, cutaneous sensibility is normal, and the reflexes are 
unchanged except when inhibited by the spasmodic state of the muscles. 

Course. — The great majority of cases run a mild course to recovery 
in a few weeks, especially if the underlying cause can be removed, but 
when tetany develops on gastric dilatation or chronic catarrhal enteritis 
it is likely to have a protracted course. Appearing generally when the 
organism is already depressed by malnutrition, it may be a formidable 
complication, and in the severe cases, where the spasms invade the trunk 
and implicate the respiratory apparatus, death by asphyxia may result. 
In pregnancy it is likely to be mild and usually terminates promptly 
after delivery, but parturition may cause very severe exacerbations of 
the attack. The lactational cases are usually manageable if the child 
be weaned and the nutrition of the patient reestablished. Tetany in 
the athyroidal state is frequently fatal ; it may be permanent and excep- 
tionally it yields to thyroid feeding. Only when Trousseau's and 
Chvostek's signs fail can the disease be considered at an end. In fatal 
cases the spasms increase in frequency, distribution, and intensity, and 
asphyxia destroys the patient, but death in tetany is more commonly 
the result of the underlying disease. 

Diagnosis. — The diagnosis is easy if the characteristic spasms are 
accompanied by the mechanical and electrical overexcitability of motor 
and sensory nerves. We have to exclude tetanus, in which the spasms 
are preceded by stiffness in the masseters which does not subside in the 
intervals between the spasms. It is also marked by nuchal rigidity and 
great general irritability. In tetanus the spasm is propagated toward 
the extremities, usually sparing the hands ; in tetany it is centripetal 
and usually begins in the hands. The phenomena of Trousseau, 
Chvostek, and Erb are absent in tetanus. Hysteria also lacks these 
special signs and has its own stigmata. Meningitis may be mistaken in 
infants, but presents none of the special signs of tetany. 

Prognosis. — The prognosis is usually good, but hangs upon the 
nature and manageability and the underlying cause. It is unfavorable 
in proportion to the extent and degree of malnutrition present. It is 
grave in the athyroidal cases, which present a mortality of about eighty 
per cent. A tendency to recurrence upon renewal of the predisposing 



540 NEUROSES. 

state is marked. Thus, some women present tetany in several successive 
pregnancies, and exacerbations of the predisposing gastro-intestinal state 
may incite a return of the tetany. Extreme severity of spasms, involve- 
ment of the respiratory apparatus, intense manifestation during labor, 
and cerebral symptoms, as in uremic cases, are of serious import. 

Treatment must be directed to the removal of the underlying causal 
state, but it is rarely necessary to interrupt pregnancy. Rickets, gastric 
dilatation, intestinal catarrh, intestinal parasites, and lactation have their 
several indications. Hygienic and sanitary conditions must be atten- 
tively studied. The spasms are controlled by quiet, rest, and warm 
baths. Bromids and chloral are useful in the interval, but morphin, 
and even chloroform, may be required for the attack. When this coin- 
cides with labor, the birth must be hastened. Chloroform must be used 
with circumspection, as it may provoke laryngeal spasm, as may also 
the employment of the stomach-tube in gastric cases. In the athyroidal 
cases thyroid feeding sometimes gives relief, but can not be relied upon. 
The administration of thyroids in other cases may also be tried. Mass- 
age, electricity, and passive movements must be avoided, as they usually 
intensify the spasms when present, and provoke them if absent. A hot 
sponge over the larynx may relieve laryngeal spasm, but tracheotomy 
may be required in rare instances. Oddo x attaches much value to the 
continuous use of calomel, which corrects the gastro-intestinal fermenta- 
tion and expels toxic substances. Dietetic regulations are often of the 
first importance. Lactate or acetate of calcium and large quantities of 
milk should be ordered. Glandular feeding with parathyroids, adrenals, 
testes, and thyroids have been variously tried without any convincing 
results. The condition of the bladder should be watched and retention 
of urine prevented. 

Vascular Trophoneuroses, 
raynaud's disease. 

Raynaud, in 1862, described a peculiar dry gangrene, especially in 
the extremities, which he attributed to a disturbance of the vasomotor 
apparatus. From present information the condition may better be 
considered as a generalized one, but with local exaggeration. Naturally, 
the circulatory disturbance is most apparent in the extremities, as in the 
lingers, toes, nose, and ears. The arterioles and venules are spastically 
contracted during the attack. Raynaud described three stages, which he 
strikingly named local syncope, local asphyxia, and local death. The 
condition is usually symmetrical, may recede at any stage short of 
gangrene, and usually appears many times in succession in mild degree 
before inducing mummification. 

Etiology. — Females furnish twice as many cases as males and no 
age is exempt, though most cases occur between twenty and forty-five. 
Sommelet, 2 however, after collecting statistics believes that it is as fre- 
quent in children as in adults. All varieties of anemia are strongly pre- 
disposing factors, and a neuropathic makeup is almost invariably present, 
i Loc. cit. 2 "Paris Thesis/' 1905. 



TROPHONEUROSES. 541 

Other nervous diseases are commonly associated, such as hysteria, epilepsy, 
tabes, neurasthenia, myelitis, and insanity, especially acute mania. Urti- 
caria, telangiectasis, angioneurotic edema, and scleroderma may be com- 
bined in the history or present in the patient. Urticaria and local as- 
phyxia may alternate in the same patient. Heredity is apparent in ten 
per cent, of the cases showing the same disorder in blood relatives. Ne- 
kam 1 reports seven children of one mother, who had been twice married, 
affected with this vascular defect. Any occupation attended by exposure 
to cold and wet may play a part in the causation. Any sudden demand 
upon the physical strength or powers of resistance may induce the attack. 
Exposure to cold is the most common immediate cause, but fright, grief, 
fatigue, trauma, influenza, malaria, and acute infections may induce it. 
Some consider the ultimate cause of the angiospasm to be an auto-intoxi- 
cation. It is often associated with scleroderma. 

Symptoms. — The local symptoms first attract attention. The 
fingers and toes, less frequently the ears, nose, and lips, or a single 
finger, appear pale, waxy, bloodless, and glossy. There is usually a 
feeling of tingling, numbness, and loss of sensibility, as in a finger 
compressed by an elastic bandage. A needle-prick draws no blood and 
the finger looks dead ; hence the term digiti mortui. After lasting a few 
minutes to several hours, this condition, often attended by chilliness, 
nausea, and general discomfort, may pass off or develop the second stage 
of local asphyxia. The affected part becomes cyanotic, blue-black, and 
the anemic pressure-trace disappears very slowly. Less commonly the 
fingers in this stage may puff up, present a vivid red color, be extremely 
hot, and covered with perspiration. There is now usually more or less 
neuralgic pain proportional to the cyanosis. Both hands may be simul- 
taneously affected or one may precede the other. One finger may, in the 
second stage, present the extreme blue-cold cyanosis, its neighbor the 
turgid, hot condition or the white, syncopic stage. If the second stage 
persists long enough, several hours at least, small blebs appear, raising 
the epidermis especially from the pads at the finger-tips, ulceration fol- 
lows, and dry gangrene may mummify and destroy the terminal 
phalanges or entire fingers. Small necrotic patches may form, and, 
healing slowly, leave cicatrices to mark the attack. The amount of 
mutilation, fortunately, is often insignificant in relation to the extent of 
cyanotic tissue. A hand or foot that appears doomed may only lose a 
few phalanges. The disease may appear in other portions of the body, 
as in patches over the deltoids, inner aspect of the calves, the heels, 
maleoli, nates, cheeks, and on the abdomen, rarely, however, going on 
to gangrene. The genitals and tongue are exceptionally attacked. 

Constitutional symptoms rarely default. Intermittent hemoglobi- 
nuria, uremia 2 with diminished urea and a lessened quantity of urine, 
and uremic convulsions are frequently noted. Attacks of colic have 
been met with during the angiospastic attack. There is no fever at 
any period except from coincident febrile disease. Cerebral disturbance 

2 "Neurolog. Centralbl.," Oct., 1904. 
x Aitken, "Lancet," Sept. 26, 1896. 



542 NEUROSES. 

is very common. l Irritability, depression, aphasia, unconsciousness, 
coma, convulsions, and mania have all been noted. The kidney symp- 
toms and the brain disturbance are apparently due to the angiospasm, 
which further shows in the narrowed retinal artery, dimness of vision, 
occasionally occurring hebetude, tinnitus, ageusia, and iridoplegia. 

Course and Prognosis. — The attacks are of variable duration and 
intensity. A few hours is usually sufficient for the local syncope and 
asphyxia to develop and subside, but ordinarily another exposure to 
cold or the incidence of any mental strain or physical fatigue occasions 
a return. When gangrenous changes have developed, several months 
are usually consumed in exfoliation and cicatrization, as the process is 
extremely slow and healing very tardy. In infants the disease is of 
rapid course and may terminate in death in a few days. In older patients 
recovery is the rule, but uremia may cause death. 

Diagnosis. — The diagnosis in a typical case is not difficult. The 
causes of ordinary gangrene are lacking, but nephritis may be present 
in Raynaud's disease. Repeated symmetrical local syncope, followed 
by regional asphyxia and passing away in a few hours, can scarcely be 
mistaken. Several bouts of lesser degree usually precede the gangren- 
ous variety, often appearing during the winter for years in succession. 
Hemoglobinuria or retention of urea greatly assists the diagnosis. 

Treatment. — The principal indication is to improve the nutrition 
and reestablish the general health. Locally, during the attack, the use 
of warm applications is indicated. The parts may be wrapped in cotton 
and the temperature properly maintained by artificial heat. Tpnitrin 
and amyl nitrite sometimes give prompt relief. Morphin, hypoder- 
matically, is sometimes required to relieve pain. The local use of the 
constant electric current has been much advocated, but the warm salt 
solutions, in which the extremities are directed to be immersed, probably 
are as active as the electricity. Cushing 2 strongly recommends the 
application of an elastic or Esmarch bandage to relieve the attack. 
When the bandage is removed, the parts rapidly fill with blood and the 
vascular spasm subsides. The treatment of the gangrene is surgical, 
but it is especially needful to wait for the demarcation line, as it often 
includes comparatively little of the threatened extremities. 

1 Osier, "Amer. Jour. Med. Sciences," Nov., 1896. 

2 "Jour. Nerv. and Ment. Dis.," Nov., 1902. 



TROPHONEUROSES. 543 



ACROPARESTHESIA, 

Schultze first, in 1890, used the term acroparesthesia to describe a 
condition which had previously been fully recognized by Nothnagel, 
Bernhardt, Putnam, and others. It occurs generally after middle life 
in hard-working women who have the hands constantly wet, as in wash- 
ing and scrubbing. The paresthetic feeling is usually a tingling, crawl- 
ing, or burning sensation, sometimes attended by decided pain and most 
marked night and morning and in winter. The hands are usually alone 
affected, but the feet may participate. The fingers may be rendered 
clumsy and awkward. The color of the skin is usually natural, but 
may be pale, whitened, or reddened. Sensibility is commonly objectively 
normal, but hyperesthesia and hypesthesia have been observed. Arteries, 
veins, and nerves are normal. There is no atrophy of muscles or integu- 
ment, but occasionally a complaint of weakness. The disorder is not 
serious, but tends to chronicity and may last many years. Cassirer 1 
notes only 12 men in 162 cases; and 106 out of 129 cases occurred 
between the ages of thirty and sixty. All occupations attended by ex- 
posure to cold and dampness are represented. The climacteric, alcoholism, 
influenza, parturition, and uterine extirpation are also noted as causal. 
The paresthesia is never limited to the distribution of a given nerve, but 
usually affects all the digits about equally, may extend to the elbows or 
even to the shoulders, and is bilateral as a general rule. The feet are 
also affected, but less frequently and less severely. 

The diagnosis must exclude Raynaud's disease, multiple neuritis, 
and scleroderma. 

The prognosis is not good as to early recovery, but favorable as to 
any serious resulting condition. 

In treatment the faradic brush, the static spark, and local galvanism 
have been accredited with favorable action. General measures, tonics, 
hydrotherapy, and, most of all, avoidance of occupational causes are 
mainly to be relied upon. Collins found intestinal disturbances of some 
sort in 57 out of 100 cases. 2 All such conditions require unremitting 
attention. 

INTERMITTENT LIMPING. 
A condition first described by the French under the term claudica- 
tion intermittente, has been designated intermittent limping by the English, 
intermittirende Hinken by the Germans, angiosclerotic paroxysmal 
myasthenia by Higier, 3 and angina cruris by Walton. 4 The condi- 
tion is manifested in pains and paresthesia, generally in the feet and 
legs, intensified on attempts at walking, and in severe cases prevent- 
ing the patient advancing more than a few steps at a time. Usually 
the feet are more comfortable in a dependent position, and in some 
cases the patient can only obtain sleep by allowing the feet to hang over 
the edge of the bed or by sleeping in a sitting posture. A recurring 

1 "Die Vasomotorisch-trophischen Neurosen," Berlin, 1901. 

2 "Med. Rec," May 31, 1892. 3 "Deut. Zeit. f. Nervenheilk. , " July, 1901. 
4 " Boston Med. and Surg. Jour.," April 3, 1902. 



544 NEUROSES. 

lameness has long been known to veterinary medicine and is found to 
be due to disease of the aorta, generally an aneurism, interfering with 
circulation in the hind extremities. In the human race it is always 
associated with, or perhaps one should say is the manifestation of ineffi- 
cient circulation in the legs and feet. In the majority of instances no 
pulse can be obtained in the dorsal artery of the foot, and in a large 
proportion of the cases the posterior tibial is also pulseless. The pain, 
which is the chief complaint, is manifested in three different conditions: 
(1) Pain upon walking ; (2) permanent pain, frequently in the form of 
painful paresthesia while the patient is at rest ; (3) the pain which 
initiates true gangrene. 

Goldflam 1 in twenty-four cases found the disorder at twenty-five 
years of age in the youngest, but usually the condition develops in mid- 
dle life and rarely after fifty. This author believes that the pathological 
condition is usually an endarteritis, although it is but seldom that any 
general arterial sclerosis is present. Erb has insisted upon an inherited 
disposition, and others contend that there is a congenitally defective 
arterial system. The abuse of tobacco or alcohol has been rather fre- 
quently noted in these cases, but the withdrawal of either or both toxic 
factors does not appear to better the condition. Syphilis was only found 
once in the twenty-four cases of Goldflam. The condition is usually 
symmetrical, and in a few instances the nerves of the part have been 
found histologically changed slightly, presenting those variations which 
are encountered in an arteriosclerosis. J. R. Hunt 2 insists that there must 
be a combination of angiosclerosis and vasomotor instability with a ten- 
dency to vascular spasm to enable the full development of the inter- 
mittent syndrome characterized by the occurrence of both sensory and 
motor manifestations during functional activity and rapid relief during 
rest. Hunt has also described an intermittent lumbar lameness of a 
similar order due, at least in one instance, to an aortic aneurism just 
above the iliac bifurcation. Massaut 3 has reported a case in which the 
upper extremities were similarly affected in a woman of twenty-four 
and no arterial pulse could be found in either arm. The painful paral- 
ysis of the upper extremity recurred upon any continuous use of the parts. 
In the majority of instances the feet are cold or blanched, but in some 
cases the parts are intensely reddened, suggesting an erythromelalgia, 
and in others the alternation between blanching and redness strongly 
simulates Raynaud's disease. It is not unlikely that the three condi- 
tions may be combined. Flat-foot has been observed in a large propor- 
tion of these cases. 

Medicinal treatment seems to have little value. Even the alkaline 
iodids, which have such a well-founded reputation in chronic arterial 
changes, give little assistance. Warm baths, massage, electricity in the 
form of the galvanic current, withdrawal of tobacco and alcohol, rest 
and general physical improvement are the measures to be adopted. 
Gangrene, when once it appears, has a tendency to extend, and early 
amputation is generally recommended. 

1 "Neurol. Centralbl.," March 1, 1901. 2 "Med. Rec," May 27, 1905. 

3 "Ann. de la Soc. med.-chir. d'Anvers," March, April, 1901. 



TROPHOXE U ROSES. 



teo 




V 



ANGIONEUROTIC EDEMA. 

Angioneurotic edema, otherwise known as acute circumscribed edema, 
acu+e non-inflammatory edema, giant urticaria, veriodic swelling, giant 
swelling, Quincke's disease, etc., was 
first definitely described by Milton, in 
1876, as giant urticaria. Dinkelacker 
and Quincke, in 1882, gave prominence 
to it under the above title. In 1892 
Collins was able to assemble seventy- 
five cases and made a critical digest of 
the literature. Since that time numer- 
ous instances have been reported all 
over the world. It is marked by acute 
circumscribed swellings of the subcu- 
taneous or submucous tissues, often 
presents a direct heredity, usually ap- 
pears in those of a neuropathic diathe- 
sis, is often periodic or recurrent, and 
is commonly attended by gastrointes- 
tinal colics. 

Etiology. — The most active pre- 
disposants are heredity and exhaust- 
ing conditions. The neuropathic taint 
may show itself in antecedent or 

associated neuroses and psychoses in the family or in the patient, or by 
the stigmata of degeneracy. This, however, is far from being an abso- 
lute rule, and numerous cases give no clue whatever to the origin of the 
neurotic disturbance. Direct heredity is often marked, as in the series 
reported by Osier, 1 in which the disease numbered 20 cases, extending 
through five generations, and the series of Milroy, 2 showing six genera- 
tions and 22 cases out of 97 individuals. Continued mental or 
physical exhaustion often prepares the field for the development of the 
vascular neurosis. The greatest number of cases appear early in adult 
life, from twenty to thirty-five years of age ; but it has been noted in 
infancy, or in the marked hereditary cases it may be congenital, as in 
20 out of 22 cases of Milroy. Both sexes are affected, but females 
somewhat more commonly than males. In several cases a decided gouty 
tendency was present. The urine showed a diminished quantity of 
urea, and the attacks were beneficially modified by reduction of nitro- 
genous diet. 

As exciting causes, exposure to cold, intestinal disorders, puberty, 
the climacteric, masturbation, traumatism, fright, grief, and the action 
of toxic agents, such as tobacco, alcohol, and malaria, have been noted 
w T ith considerable frequency. In some instances the malarial intoxica- 
tion has caused quotidian or tertian attacks. In some they have recurred 



Fig. 228. — Angioneurotic edema involv- 
ing the lower portion of the face in a very 
snare individual. 



35 



1 "Atner. Jour. Med. Sciences." April, 1888. 

2 "New York Med. Jour.," Nov. 5, 1892. 



546 NEUROSES. 

every seventh or twelfth day. Aside from such periodicity they have a 
tendency to develop during the latter half of the night, when the circu- 
latory activity is at its minimum. They also show a seasonal increase 
in winter and summer, apparently the result of temperature changes 
and chilling of the skin, and sometimes they follow slight blows. 

Symptoms. — The swellings of angioneurotic edema generally 
appear without warning, and reach their maximum in a few minutes or 
in an hour or two. The most usual locations are the face, lips, tongue, 
pharynx, genitals, and extremities. The hands are frequently affected. 
The buttocks, shins, or abdomen may be selected. The swelling is 
tense, sharply denned, not tender, does not pit on pressure, is whitish 
or pinkish, and rarely marked by purpuric discolorations. It lasts from 
a few hours to several days, and vanishes as rapidly as it appears, 
leaving no trace, or as it leaves one locality a similar swelling may show 
itself elsewhere without symmetrical or anatomical relation. Several 
swellings may appear at once. In amount, the swelling varies greatly, 
but may attain large proportions ; hence the name giant swellings. 
Sometimes nodular swellings as large as heir's eggs are encountered. There 
is usually a subjective feeling of tension and stiffness in the parts, and 
some burning, prickling, or itching. If the skin is scratched, urticarial 
stripes and wheals usually appear, or they may attend the attack or 
alternate with it. 

The tongue, larynx, pharynx, stomach, and intestines are sometimes 
affected by the swelling, and local discomfort and even serious danger 
to life may result. Dyspnea, difficulty of swallowing, intestinal and 
gastric colic are thus induced, and several cases have perished from 
the laryngeal occlusion. Gastro-intestinal symptoms are very common 
and appear in from one-half to one-third of the cases. A feeling of 
uneasiness in the epigastrium is followed by distention, nausea, and 
obstipation. Colic, cramps, profuse vomiting, and intense thirst ensue. 
The attack terminates with a colliquative diarrhea. There is often a 
great increase in the urinary excretion during the attack, and albuminuria 
and hemoglobinuria are not infrequently encountered. An effusion into 
the joints sometimes take place. Cerebral symptoms sometimes indicate 
an edematous involvement of the brain. Lassitude, somnolence, head- 
ache, coma, slow pulse, general or localized convulsions, have been noted. 
The cases of regularly intermittent joint effusion in which a painless 
swelling of the joint recurs every week or two are of this nature. 1 The 
attacks may come on at various intervals of days, weeks, or months, or 
with regularity, and ordinarily between the attacks the previous general 
condition of health is regained. A blow is sufficient to induce and locate a 
swelling in some cases, and there is a tendency for the swelling to recur con- 
stantly in the same locations. In some of the congenital cases the swelling 
is practically permanent, general as well as intestinal symptoms being ab- 
sent. Occasionally there is an association of erythema and angioneurotic 
edema, the redness and swelling being of similar or dissimilar distribution. 

Diagnosis. — The diagnosis can present little difficulty if one is on 

1 Schlesinger, "Die intermittirenden Gelenkschwellungen," "Nothnagel's Spec. 
Pathol.," 1903. 



TROPHONE U ROSES. 



547 



guard. We must differentiate the erythematous nodosities of rheu- 
matism, the persistent blue and white edemata of hysteria, and the 
edemata of renal and cardiac origin. 

Prognosis. — There is little danger unless the larynx be affected, 
and there is a general tendency for the attacks to cease in advanced 
years, though sometimes they last for life, or may reappear after a long 
interval. If traceable to inciting causes, the immediate prognosis is 
improved. If dependent upon toxic conditions due to alcohol, tobacco, 




Fig. 229. — Symmetrical liuoxuata; three pairs, one over mastoids, one over maxillary articulations, one 

under angle of jaw (^Beck). 



malaria, lithemic, or gastro-intest nal infection, the proper intervention 
promises good results. 

Treatment. — If the cause can be discovered and removed, the 
neurosis promptly yields. Otherwise reliance must be placed on those 
general measures which are fitted to combat the neuropathic constitution 
and build up the usually depraved systemic condition. The treatment 
of the attack is symptomatic. Morphin for gastro-intestinal crises, heat 
and compression to the swelling, and tracheotomy or intubation if 
respiratory failure is seriously threatened. Bloodgood * reports several 
cases of persisting angioneurotic erythema cured by deep incisions. 

1 "Johns Hopkins Hospital Bull.," May, 1903. 



.548 NEUROSES. 

Hypertrophic Trophoneuroses, 
hyperostosis cranii 

Virchow used the term leontiasis ossea, Starr, megalocephalie, and 
Putnam, hyperostosis cranii to designate certain rare cases in which the 
bones of the cranium, and less markedly those of the face, undergo 
enormous enlargement. The process is' apparently inflammatory in 
character, but its symmetrical distribution, association with develop- 
mental periods of life, and progressive nature point to a lack of trophic 
control. Putnam, 1 accepting seven from Baumgarteir's list, has been 
able to tabulate fifteen cases, including that of Edes. Morton Prince 2 
believes that this condition is but a part of osteitis deformans, with 
which it is sometimes associated, and that both are of neuropathic 




Fig. 230.— Hyperostosis cranii (Putnam). 

origin. In the majority the disease appears under thirty years of 
age, and often in childhood or at puberty. The cranial enlargement 
is sometimes preceded by inflammations about the head, such as erysip- 
elas, and by traumatism. Early symptoms have been headache, drow- 
siness, epileptic attacks, deafness, and blindness. Mental irritability or 
enfeeblement is common. Exophthalmos, loss of hearing, facial palsy, 
optic neuritis, and blindness are due to local or intracranial pressure. 
The anterior portion of the head is usually most enlarged, and the upper 
facial bones are more affected than the inferior maxilla. Prognathism 
1 "Amer. Jour. Med. Sciences," July, 1896. 2 Ibid., Nov., 1902. 



TROPHONEUROSES. 549 

is not commonly observed. There is usually a large increase in the 
bitemporal diameter. In some instances the bones are rather evenly 
enlarged ; in others there are numerous exostotic thickenings, both on 
the outer and inner surface of the cranium, or on either aspect alone. 
The cervical vertebrae are sometimes also enlarged. The disease is 
progressive and not amenable to treatment. Putnam, Starr, and others 
have tried thyroids in vain. Encephalic pressure may in suitable cases 
be relieved by trephining. Probably a number of different conditions have 
been grouped under this title. Some instances have shown unmistak- 
able pituitary disease. The bony enlargement of the head has been 
associated with persistent infantile conditions, and in later cases with 
sexual devolution. They may constitute aberrant links between more 
distinct clinical types of excessive and defective pituitary activity, 

HYPERTROPHIC OSTEOARTHROPATHY. 

In 1890 Marie and, independently, Bamberger described cases of 
chronic intrathoracic disease attended by skeletal deformities. For 
such, Marie proposed the term osteo-arthropathie hypertrophiante pneu- 
mique. Massalongo, Thayer, and others insist that the pulmonary factor 
is by no means essential, and Thayer * found it absent in 12 out of 55 
typical cases. Other chronic conditions to which it is secondary are 
syphilis, heart disease, diarrhea, and spiual caries. It has been associated 
with phthisis, empyema, bronchiectasis, pulmonary syphilis and neo- 
plasms, pleurisy, bronchitis, and gastric dilatation. The disease pre- 
sents a multiple osteitis, affecting mainly the terminal phalanges of the 
hands and feet, the extremities of the long bones of the limbs, and the 
neighboring joints. The affected bones are enlarged, rarefied, and show 
the evidence of inflammation. The cartilages are eroded, the synovial 
membranes thickened. The bones, however, may escape, 2 the enlarge- 
ment of the finger-ends being due to an excess of subcutaneous fat. 
The fingers, owing to the globular enlargement of the distal phalanges, 
have been likened to drumsticks. The nails are greatly enlarged and 
overhang the thickened finger-ends like a parrot's beak. Usually they 
are thin and smooth. The joints creak and grate on motion, and the 
ankles and wrists are ordinarily broadened and thickened. Elbows 
and knees may be similarly affected, and the toes show deformities and 
disproportions similar to those of the fingers. The invariable presence 
of chronic toxemic states indicates a toxic basis for the trophoneurosis ; 
for instance, Preble 3 noted it in a case of gastrectasis. 

The disease usually is of insidious onset and is frequently attended 
by rheumatoid pains. It may occur at any age. 

The diagnosis is commonly easily made, though at first this dys- 
trophic disease was confused with acromegalia. It does not affect the 
head, face, or soft parts, and does involve the joints. In acromegalia 
the fingers and toes are uniformly enlarged, and the wrists and ankles 
are not disproportionately increased in size. The facies of acromegalia 
is never seen in pulmonary osteo-arthropathy. 

The disease runs a protracted course, but may come to a standstill, 

1 "Phila. Med. Jour.," Nov. 5, 1898. 

2 E. F. Buzzard, "Br. Med. Jour.," June 1, 1902. 3 "Medicine," Jan., 1898. 



550 NEUROSES. 

or it may recede slightly if the thoracic condition is greatly improved. 
Desmons and Beraud 1 report some improvement following subcutaneous 
injections of extracts made from sheep's lungs. 

LOCALIZED HYPERTROPHIES. 

Symmetrical Lipomatosis. — Occurring commonly in adults, and 
usually on a background of syphilis or alcoholism, are cases manifesting 




Fig. 231. -Symmetrical adenolipomatosis (Launois and Bensaude). 

localized and symmetrical fatty deposits. These may be tender and the 
seat of spontaneous pain or comparatively insensitive, and the pain may 
be quite insignificant. Their favorite location is about the neck, the 
diffuses Lipoma des Halses of the Germans ; over the body, as in the 

4 "Archives gen. de Med.," 1894. 



TROPHONEUROSES. 



551 



case of Hugier, which presented twenty symmetrical pairs; in the 
axilla? and groins; or on the extremities, as in the case reported by 




Fig. 232.— Maerodactyly : localized hypertrophy of a single finger (Ridlon). 

Mathieu, one pair over the trochanters, one pair on the inner side of 
the knees. The adenolipomatosis of Launois and Bensaude 1 (Fig. 231) 
appears to belong to the same group. 




Fig. 233.— Chronic hereditary tropho-edema in sisters at seventeen and twenty-one years of age (Meige). 

The ill-defined fatty masses are commonly spread out at their bor- 
ders. Surgical removal of the fatty tumors is sometimes indicated. 
1 "Nouv. Icon, de la Salpet.," 1900. 



552 NEUROSES. 

Unsymmetrical Hypertrophies. — In rare instances, usually con- 
genital, and frequently of neurotic ancestry, one side of the body or 
one extremity, or a portion of an extremity, as a hand or one or more 
digits, may be disproportionately large. The asymmetry usually in- 
creases with the child's growth. In still rarer cases it makes its 
appearance after birth, and may occur at any time up to maturity. The 
hypertrophy usually involves the affected portions en masse, so that the 
increase in length is proportionate to the breadth and thickness. The 
principal increase is usually in the adipocellular tissue, but the muscles 
may be hypertrophic and may show correspondingly increased strength. 
Usually, however, the muscles are defective. The bones are simply 
enlarged. Sometimes the hypertrophied parts are warmer than their 
normal fellows and may show increased perspiration and evidences of 
hyperemia. Occasionally there are pigmentary markings. Hemihyper- 
trophy of the face may be encountered, and Friedreich reports a case 
presenting hypertrophied left face and arm and right leg. In rare 
instances such localized hypertrophies are seen in gigantism and acro- 
megalia. Of their nature we know practically nothing. In some 
instances it has been attempted to check the overgrowth by compressiug 
the arterial supply and by the injection of astringents, but no good 
seems to have resulted. Enlarged digits may be amputated. 

Chronic Hereditary Tropho- edema. — Henry Meige 1 describes a 
family in which edema affected eight members, both men and women, 
distributed through four generations. Four of these cases were observed, 
and present the same singular affection : namely, a chronic white, firm, 
and painless edema, appearing at the age of puberty, and affecting 
especially the feet and legs and sometimes the entire lower members, 
generally on both sides. He also refers to a remarkable family reported 
by Milroy, 2 in which in six generations there were twenty-two cases. 
Other similar family groups have been published, and A. Thomas 
thinks that one-sided hypertrophies of the body belong to the same 
category. 

The condition in all known instances has caused but little inconveni- 
ence, has been attended by no suffering, has not shortened life, and has 
resisted all forms of treatment. 

1 "Nouv. Icon, de la Salpet.," Dec, 1899. 

2 "New York Med. Bee.," 1893. 



INFECTION NEUROSES. 553 



CHAPTER II. 
INFECTION NEUROSES. 

The diseases now temporarily grouped among the neuroses because 
the essential histological lesions of the nervous apparatus still escape us, 
but due to the action of infections, are tetanus, hydrophobia, and chorea. 
In the first two the infection is capable of experimental propagation; 
in the last the nature of the poison is as yet an inferential matter. All 
present a preponderance of motor symptoms. Tetanus and hydro- 
phobia are properly surgical conditions, and will be very briefly out- 
lined. 

TETANUS. 

Tetanus is an acute infectious disease marked by tonic spasms of the 
voluntary muscles, usually commencing in those of the jaws ; hence the 
names trismus and lockjaw. 

Etiology. — The disease is comparatively more common in hot 
climates and in the colored races than among Caucasians in temperate 
and cold regions. This may have relation to the better protection by 
footwear and clothing in the latter conditions. It spares neither age 
nor sex, and is a common disease among horses. It may occur endemic- 
ally. It is probably always introduced traumatically, and can usually 
be traced to inoculation by objects contaminated by the ground-soil, in 
which the bacillus of tetanus readily lives. Naturally, the hands and 
feet are the most common locations of such contaminated abrasions or 
more extensive lesions. The bacillus first discovered by Nicolaer, and 
cultivated by Kitasato, is an anaerobic, drumstick-shaped, motile microbe. 
Culture filtrates contain tetanizing poisons which are active when inocu- 
lated, but not when ingested. Experimental evidence indicates that, 
like strychnin, their action is mainly upon the spinal cord. 1 

Morbid Anatomy. — The condition of the wound presents nothing 
characteristic, and in the brain and spinal cord the congestion, perivas- 
cular exudation, small hemorrhages, and pigmentation of cells some- 
times encountered are neither constant nor distinctive. They may even 
be looked upon as the results of the spasmodic conditions that mark the 
clinical course of the infection. The same is true of the serous ecchy- 
moses, pulmonary congestions, and muscular ruptures. 

Symptoms. — From two to twenty days or more after inoculation 
the first symptoms appear. The intensity of the disease and its fatality 
are usually in direct proportion to its early onset. Stiffness of the neck- 
and jaw-muscles first appears, limiting mastication, the movement of 
the tongue, and of the head. Kernig's symptom appears early, and per- 
sists continuously throughout the clinical period. 2 Malaise, chilly sen- 

1 Wasserman and Takaki, " Berlin, klin. Wochens.," June 3, 1898. 

2 Kostowzew, " Berlin, klin. Wochens.," 1908, No. 36, 37. 



554 NEUROSES. 

sations, or rigors may antedate the muscular stiffness, but usually do 
not attract much attention. The muscular spasm increases in intensity 
and invades the face and trunk. From the tonic action of the zygomatic 
group the angles of the mouth are retracted in a characteristic sardonic 
grin that uncovers the teeth, and the jaws can be only slightly separated 
or may be quite immovable. The head is then retracted, and the entire 
back may be affected, causing rigidity or, in greater degree, opisthotonos. 
In some cases the trunk is bent laterally or forward. The lower extremi- 
ties are usually more affected than the upper, and the forearms and 
hands are last and least involved. The muscular spasm is chiefly tonic, 
but if the condition becomes well marked, there are sharp, short, convul- 
sive exacerbations that may reach a most frightful intensity. They are 
then provoked by the slightest irritation, such as a sudden noise, a bright 
light, a touch, the jarring of the bed, or any motor effort. They may 
occur a few times a day or, in extreme cases, with great rapidity, at 
scarcely noticeable intervals. When these develop they are attended 
by pain proportional to their intensity and duration. They may impede 
the thoracic respiratory excursions or induce laryngeal spasm and 
dyspnea or asphyxia. Often the thoracic or laryngeal spasm induces a 
hoarse noise, which, taken with the distorted face, rigid limbs, retracted 
head, and opisthotonic position, presents a frightful picture. Profuse 
perspiration may be occasioned. The temperature may be normal, 
slightly increased, or hyperpyrexia may appear and ordinarily precedes a 
fatal termination. Through it all the mind remains unclouded. 

Varieties. — Head tetanus or cephalic tetanus follows wounds upon 
the head, face, or neck ; is usually of prompt appearance after the inocu- 
lation ; is ordinarily marked by trismus, dysphagia, facial palsy, and 
respiratory difficulty, a rapid course, and a fatal termination. The mod- 
ification of tetanus in this form appears to be due to early poisoning of 
the medulla. The facial palsy that frequently and the oculomotor pal- 
sies that sometimes occur indicate nuclear disturbance. The difficulty 
in swallowing gives a rough resemblance to rabies and has led to the 
term tetanus hydrophobicus. Tetanus neonatorum is usually due to 
infection of the umbilical stump, and is unknown to aseptic midwifery. 
Puerperal tetanus occurs in parturients. The invasion route is usually 
through the uterus. 

Diagnosis. — Given a locus of inoculation, the disease can scarcely 
be mistaken. When a history of trauma is wanting hydrophobia may 
be suspected, but lacks the jaw-spasm and persistent muscular rigidity. 
Strychnin poisoning is a closer imitator, but has a more rapid onset, more 
violent and extensive convulsions, trismus is absent, and relaxation 
occurs between the spasms. Tetany affects the hands and feet mainly 
and primarily and shows a number of special reactions, such as increased 
electrical excitability and Trousseau's sign. Hysteria may imitate 
tetanus, but ordinarily gives a hysterical history and presents the stig- 
mata of the neurosis. It also usually appears suddenly after a hyster- 
ical convulsion, suddenly disappears and recurs, and lacks the nuchal 
rigidity and mental clearness of tetanus. Bacteriological examination 
of pus from wounds may make or confirm the diagnosis. 

Prognosis is always grave and the mortality is over eighty per cent. 



INFECTION NEUROSES. 555 

Cases appearing before the sixth day usually die ; those appearing after 
the twelfth day are likely to recover. Death results from apnea and 
heart-strain. Favorable indications are : late onset, limited muscular 
spasm, absence of respiratory and medullary symptoms, infrequency of 
convulsions, normal temperature, and ability to receive and assimilate 
nourishment. 

Treatment. — If the wound of entry for the tetanus infection is in 
an unhealthy state, surgical measures of local disinfection are always in 
order, and usually consist of scraping, cauterization, and the employ- 
ment of active germicides. Lambert x believes that hydrochloric and 
carbolic acid together furnish the best local application. It often hap- 
pens that the infection atrium is completely healed, and even early 
cauterization seems to be of doubtful assistance in checking the disease. 
The general management is of prime importance. The patient should be 
secluded in a darkened room and every possible excitation be prevented. 
Alimentation should be carefully maintained by easily digested fluid 
foods, and, if necessary, by the use of the nasal tube or by rectal injec- 
tion. Sedative drugs and antispasmodics are indicated, and various ones 
have cures credited to them. Chloroform and nitrite of amyl are 
useful to meet the convulsions. Chloral, bromids, morphin, calabar 
bean, and curare are advised, but must be used with a free hand or 
omitted entirely. Hot baths sometimes act most soothingly. Active arti- 
ficial respiration is required in case of dyspnea and threatened asphyxia. 
Immunization of late years has been attempted by the use of the anti- 
toxins introduced by Tizzoni and Catani. They have been found 
practical and reliable in animal experiments. There is much diversity 
of opinion regarding their value in human tetanus. Kneass, 2 from a 
tabulation of sixty-one cases treated by tetanus antitoxin, finds an insig- 
nificant advantage over the older medicinal methods, and Berger, Roux, 
Yandell, and others are of the same opinion. Lambert R states a mor- 
tality of thirty-seven per cent, under the antitoxin in acute cases devel- 
oping within eight days of the infection. It is not unlikely that the 
antitoxins will be so much improved as to give better and more reliable 
results, and they can not well be omitted in the treatment of this disease. 
They are valuable in proportion to their early use. Antitoxin has been 
injected into the substance of the brain through trephine openings in 
order to bring it quickly into operation, but the results hardly warrant 
the method. Intraspinal, subdural, intravenous, and subcutaneous injec- 
tion are less objectionable and probably equally efficacious. The re- 
moval of spinal fluid and the intradural injection of eucain and mor- 
phin has been of apparent benefit. Intraspinal injections of magnesium 
sulphate, 1 c.c. of a 25 per cent, solution to each 25 pounds of body 
weight, after the method of Meltzer, is strongly recommended by some. 
Baccelli employed subcutaneous injections of carbolic acid, using a 2 per 
cent, solution and beginning with a dose of 0.3 to 0.5 c.c, increasing 
gradually to 1. c.c. every four to six hours, being guided by the symptoms 
and the urine. At present, medicinal preparations are also imperatively 
demanded in the treatment of tetanus. 

1 "Amer. Jour. Med. Sciences," Aug., 1897. 

2 "Jour. Am. Med. Association," July 18, 1896 3 Loc. cit. 



556 NEUROSES. 

HYDROPHOBIA, 
Hydrophobia is an acute, infectious disease of carnivorous animals, 
transmissible to man and to other animals by inoculation. It is also 
known as rabies and lyssa. The inoculating animals usually are dogs 
or wolves, but the cat, skunk, and even poultry may carry the disease. 
The exact nature of the poison is unknown. It undoubtedly is a living 
contagium. The disease is rare in this country, but seems to be growing 
more common in the Eastern States, and almost invariably, in man, is the 
result of bites by rabid dogs. In North Germany, where the muzzling 
of dogs is rigidly enforced, the disease is almost unknown. It is, 
therefore, in civilized countries a preventable disease. 

Morbid Anatomy. — The nervous system frequently shows lesions, 
but these may be completely lacking and to some extent, when present, 
are secondary to the disease, following the spasms, dyspnea, and cardiac 
failure. They consist essentially of vascular disturbances : dilatation, 
perivascular leukocytal infiltration, ante-mortem intravascular clots, and 
minute hemorrhages. Such changes are most frequently encountered in 
the cortex cerebri, the medulla, and cord. According to Gowers, they 
are most intense in the neighborhood of the pneumogastric and hypo- 
glossal nuclei. The perivascular infiltration in this locality may be 
intense enough to suggest miliary abscesses. The presence of Negri's 
bodies in the nerve-cells of the cord and brain is now looked upon as 
positive evidence of rabies. Their exact nature is still undetermined. 
They are round or oval, from 1 to 30 microns in size, and very persistent 
in character. Negri supposed them to be parasitic. It is probable from 
various analogies with poliomyelitis that similar almost ultramicro- 
scopical organisms will eventually be isolated in this terrible disease. The 
salivary glands and kidneys frequently show round-celled infiltration and 
the mucous membrane of the pharynx and larynx is commonly congested. 

Symptoms. — Incubation requires a variable period of from two 
weeks to six months, and there are reported cases occurring twelve and 
even eighteen months after inoculation, the virus having remained 
dormant. The ordinary incubation period is six weeks to two months. 
The length of incubation time, according to Horsley, is modified by a 
number of factors : (1) It is shorter in children than in adults. (2) 
Wounds of the face, neck, head, and hands, and the unclothed parts 
are especially dangerous, and the disease then develops promptly. (3) 
Punctures are the most dangerous ; lacerations are serious in proportion 
to their extent. (4) The bites of rabid animals are serious in this order : 
Wolf, cat, dog, and other animals. About fifteen per cent, of the persons 
bitten by dogs known to be rabid develop hydrophobia. 

Rabies varies in intensity in both animals and man. In cases of 
great severity paralytic features develop early, there is little excitement, 
and death promptly supervenes. When the poisoning is less profound, 
the disease runs a longer course, and presents a period of great motor 
and cerebral excitement. In man the invasion of the disease is fre- 
quently marked by irritation about the wound, with pain or numbness. 
Usually there is headache, depression, loss of appetite, irritability, 
sleeplessness, and anxiety. The pulse and temperature may be slightly 
increased. Bright lights, noises, and slight excitement of any sort are 



INFECTION NEUROSES. 557 

shunned owing to the increased sensibility. Stiffness of the throat- 
muscles and difficulty in swallowing are noticed. A period of excitement 
then usually develops, when, in rare instances, the central apparatus may 
be overwhelmed and the paralytic form, with ascending paraplegia and 
heart- failure, terminates the case within a comparatively few hours. In 
the excited period there is great motor restlessness and hypersensibility : 
spasms affecting the throat are induced by any fictitious stimulus, and 
swallowing becomes impossible, so that fluids are shunned, and the sight 
of them may even become unbearable; hence the name, hydrophobia. 
Noises, lights, a breath of air, may provoke the spasm; and it may 
involve the larynx and thorax, producing dyspnea, cyanosis, and an 
alarming asphyxia that even tracheotomy may fail to relieve. The 
respiratory and deglutition spasms are often attended by hoarse sounds 
and peculiar noises, that have been thought by excited laymen to 
resemble the barking of dogs. Saliva accumulates in the mouth or 
drules from its corners, partly from an increased secretion, but mainly 
from difficulty in swallowing. Hallucinations and delirium are fre- 
quently present, but the mind may be quite clear and the patient quiet 
between the paroxysms. The temperature commonly ascends to 100° 
or 103°, but the disease may be afebrile throughout. The spasms 
gradually become wide-spread and tetanoid, but rarely affecting the 
jaw and face, and relaxation occurs in the intervals. After one to 
three days they are followed by the paralytic period, and spasms no 
longer occur. An ascending paraplegia is commonly presented. Quiet, 
stupor, and coma follow ; the heart's action becomes greatly weakened, 
and death follows syncope. 

Diagnosis. — The diagnosis of a well-developed case, with motor 
excitement and a history of a bite by a rabid animal, can be readily 
made. AVe have to exclude tetanus, in which there is usually a very 
recent trauma, masticatory spasm, constant rigidity, and little or no 
difficulty in swallowing. Lyssophobia is a hysterical condition occur- 
ring in a neurotic, and is a variety of hypochondriasis with the fixed 
idea of rabies. The attacks that occur are hysterical exaggerations of 
the newspaper accounts of rabid patients, and such cases can usually 
be deciphered by the concomitant indications of hysteria. Every such 
case should, however, be carefully watched if it is reasonably certain 
that the patient has been bitten by an animal suspected of rabies. In 
every case it is also important to diagnose the condition in the alleged 
rabid animal, and this can be done with certainty if the Negri bodies 
are found, or inoculation experiments can be made. 

In case of a bite by a dog, the animal should be placed under ob- 
servation, if possible, and not destroyed. The saliva being highly pois- 
onous, a little of it may be inoculated into the dura of a dog or rabbit, 
and precise results obtained. In dogs, the paralytic form of rabies is 
the most common, the furious form exceptional. The early symptoms 
in the dog consist of dulness, irritability, and surliness, the bark becomes 
metallic, food is neglected, but bits of wood, dirt, and other indigestible 
articles are sometimes swallowed. If furor develops the dog runs, 
snapping at everything in its way, especially attacking other dogs. 
Children, being unaware of danger and less able to escape, are more 



558 NEUROSES. 

frequently bitten than adults. After a day or two, or a few hours only 
in some cases, paralytic symptoms set in. The animal becomes uncer- 
tain on its legs, the hinder limbs give way, and the paralysis becomes 
general, ending in death. The excited stage is commonly transient, 
and paralytic conditions promptly develop. 

Treatment. — An inoculated wound, or one reasonably suspected, 
should be treated locally, at the first possible moment, by thorough cau- 
terization, or excision, if practicable. The use of a ligature above the 
wound when on an extremity, suction, and free bleeding are also of 
value. The actual cautery, a bunch of burning matches, strong carbolic 
or nitric acid, may be used. Immunization by Pasteur's method is now 
practicable in most large cities. The sooner it is undertaken, the more 
successful it is likely to be. Less than one-half of one per cent, of all 
cases treated in this way have died of rabies. When hydrophobia de- 
velops in man, about the same treatment is required as in tetanus. 
There is no danger to attendants, and no case is on record where the 
disease has been transmitted from man to man. Forcible physical con- 
trol is practically never needed. If food and drink can be swallowed, 
it should be freely given, but rectal alimentation is usually required. 
Chloroform, bromids, morphin, and sedatives are palliative only. The 
disease is invariably fatal. 

CHOREA. 

It is desired to limit the term "chorea" to a definite morbid entity. 
The choreiform features of hysteria which mark epidemics of St. Vitus' 
dance, hereditary chorea, or the so-called chorea major of Huntington, 
the electric chorea of Dubini, habit chorea or the maladie des tics, and 
the various forms of myoclonus should be carefully distinguished from 
minor chorea or the chorea of Sydenham, with which we are now to deal. 
It is commonly called St. Vitus 7 dance, but that term may better be re- 
served for the hysterical forms. 

" Chorea," judicially says Osier, * " is an acute disease of childhood, 
rarely of adults and of the aged. Characterized by irregular, involun- 
tary movements, a variable amount of physical disturbance, and asso- 
ciated very often with arthritis and endocarditis. The disease is usually 
considered as a neurosis, but the clinical characters of the severe cases 
and the frequent heart and joint complications have suggested to many 
recent writers that it may be due to a specific poison." 

Etiology. — Predisposing Causes — Sex. — Girls are affected somewhat 
more than twice as frequently as boys, and the disproportion becomes 
even greater after puberty. The vast majority of cases develop between 
five and sixteen years of age. Chorea is comparatively rare before the 
age of four. The reported congenital cases are usually mistaken in- 
stances of organic cerebral disease. After twenty the disease is most 
rare, but may appear in advanced years. The great majority of reported 
senile cases, however, are instances of motor disturbance symptomatic 
of organic brain lesions. It is somewhat more common in unhygienic 
and cramped conditions of life, and hence in urban communities, but 
spares no social grade or locality. Chorea is extremely rare in the 
1 On "Chorea," Philadelphia, 1894. 



INFECTION NEUROSES. 559 

dark-skinned races on this continent, Negroes and Indians of full 
blood are very seldom affected. The seasonal relations of the disease 
are most interesting. According to Lewis, the frequency of chorea 
reaches its lowest curve in November, but rises rapidly in December, 
remains stationary in January and February, mounts still higher — to 
its acme — in March, falls in April, again rises in May, and then gradu- 
ally declines to its November starting-point. This trace corresponds 
with that of rheumatism, the general amount of sickness, and climatic 
vicissitudes. The neurotic make-up plays a distinct predisposing 
role, so that we learn to expect a history of various neuroses and psy- 
choses in the family, and of " nervousness " in the patient. Choreics 
commonly show some of the so-called stigmata of degeneracy and often 
give a history of pavor nocturnus, enuresis, infantile convulsions, febrile 
deliriums, impressionability, and mental precocity. It is not rare to 
find that the mother has had chorea. 

Inciting Causes. — Fright, worry, especially at school ; mental shock and 
strain generally, and overstudy particularly, are frequently alleged in- 
citing causes, but on close analysis usually retain but little significance. 
Very frequently the early mental and even motor symptoms of the 
disease and of rheumatism will be found to have antedated the psychic 
trauma that precipitated the choreic storm. Imitation plays a most in- 
significant, if not entirely negative, role. A case of true chorea in a 
school or home for children may, however, start an epidemic of hys- 
terical St. Vitus' dance, or of hysterical rhythmic spasms. Hysteria 
may, indeed, ape chorea to the minutest detail, and they may be associated. 
Traumatism can not be dissociated from mental shock, and parents 
always assiduously seek for some such incident and cause. Its real 
value as an etiological factor is difficult to estimate, but seems slight, 
and often the particular injury is but one of the insignificant mishaps 
of every-day life in childhood. Reflex irritation, prominently urged by 
the older writers, arising from the intestines, and particularly from 
worms, is seldom found, but should not be overlooked. Diseased con- 
ditions in the nasopharynx are more likely to induce tics than chorea, 
and the same may be said of eye-strain, the fetich of some recent 
writers. Tonsillar and adenoid disease, however, is on a closely related 
footing with both chorea and rheumatism. If the ocular apparatus is 
unbalanced or refractive errors are found, they should be relieved here 
as well as elsewhere. It is not unreasonable to suppose that their del- 
eterious influence may protract the nervous manifestations of chorea, 
or may predispose to it by lowering the general tone. Pregnancy appears 
capable of causing a recurrence of chorea or of favoring its development 
and modifying its course. The chorea of pregnancy furnishes one of the 
varieties of the disease, and accounts in part for the larger proportion 
of female cases in adult years. As strongly urged by Tourette, many 
such cases are purely hysterical, though commonly considered choreic. 
Chorea is sometimes preceded or accompanied by the infectious diseases 
of childhood, as might naturally be expected, given the fact that chorea 
is especially a malady of early life. The relationship is mainly one of 
coincidence. They may, however, modify the chorea. Occurring during 
its early period, they tend to intensify it, but if it be on the wane, they 



560 NEUROSES. 

seem not rarely to hasten its regression. The favorable influence, if 
it exists, may perhaps be attributed to the forced rest they necessitate, 
and we are to see that rest is the most important element in the treat- 
ment of chorea. Anemia and malnutrition sometimes precede chorea, 
and may furnish a certain liability to its invasion, but usually they 
follow its development and are symptomatic of it. 

Rheumatism (Cardiopathy, Arthritis). — The questions arising re- 
garding the relations existing between rheumatism and chorea are 
interesting and practically important. In order to start aright, it should 
be stated that rheumatism is here meant to broadly signify the acute 
manifestations of an infectious process that is marked by inflammatory 
disturbance of articular, serous, and endocardial surfaces. This is pre- 
sumably a heteropathic disorder, but in most instances due to the 
activity of an unknown specific micro-organism ; unless we accept as 
such the streptococcus isolated by Triboulet, AVasserman, Pain and 
Poynton, and Benton and Walker, or consider it some modification or 
variant of the ordinary streptococcus, according to Rosenow. It has 
long been observed that acute rheumatism and cardiac lesions may 
precede, attend, or follow chorea. Different observers find such rela- 
tion in widely varying ratio. One sees rheumatism in "growing pains"; 
another requires that all the articular manifestations should be present 
to justify its recognition. The most reliable statistics give a rheumatic 
association in about 20 per cent, of all cases. Thus, Osier, 21 per cent, 
and 18.24 per cent, in two series; Townsend, 21; Crandall, 54; Starr, 
18; the British Collective Investigation, 22 per cent. Usually the arthri- 
tis precedes the chorea, rarely it follows, and exceptionally it develops 
during the progress of the motor disturbance. If the milder manifesta- 
tions of rheumatism are accepted in this connection and allowances 
made for the unrecognized cases, it is permissible to say that it is asso- 
ciated with chorea in one-half of all cases. Fatal cases of chorea almost 
invariably show endocardial vegetations which differ in no particular 
from those due to rheumatic endocarditis, yet such cases give a rheu- 
matic history in only about 25 per cent. 

Pathogenesis. — It is needless to even enumerate all the theories 
that have been advanced regarding the nature of chorea. Those now 
advocated may be divided into the neurotic, the infectious, and the 
rheumatic theories. Granting that acute rheumatism is an infectious 
disease, the third division is embraced in the second. The neurotic 
theory is based largely upon the appearance of the disease during the 
vears of active growth, the common neurotic peculiarities and antecedents 
of the patients, the incitement by mental shocks, the psychical symptoms, 
and the complexity of the nervous disorders, which embrace motor, reflex, 
and sensory troubles. Even the arthritis has been referred to a nervous 
source. Charcot said it was the old question of arthritism in combina- 
tion with nervous diseases. Joffroy denominates chorea as a cerebro- 
spinal neurosis of the period of growth. 

The theory of infection rests upon the influence of age, sex, and 
season ; the association of chorea with other infections, its intimate rela- 
tion with rheumatism; the infectious aspects of fatal cases clinically, and 
the presence of endocarditis at practically every autopsy, often accom- 



INFECTION NEUROSES. 561 

panied by pericarditis, pleurisy, parotitis, abscess formation, and other 
septic processes. Finally, there are those who, following Kirkes, Roger, 
and others, see in chorea only a manifestation of rheumatism. This 
theory of identity is recently maintained by Churton. 1 He says : 
" The postulated toxin (x) being accepted as an essential element in 
the causation of rheumatism, depressing conditions (y) determine the 
first position or locus (z) of the disorder. . . . If (y) is a fright, 
shock, or intense excitement, (z) will be the nervous system ; in the 
developing brain of a child the result is usually chorea ; in adults it may 
be delirium or coma, perhaps hyperpyrexia. . . . Wetting of the 
feet always causes arthritis first in the lower extremities ; of shoulders, 
in the upper extremities." The embolic theory of Kirkes, upheld by 
the experiments of Money, was based on the supposition that endocar- 
ditis always preceded chorea, which can not be maintained. 

As to the precise location of the disease in the nervous system, the 
mental symptoms, frequent monoplegic or unilateral distribution of the 
chorea, and the practical exemption of the trophic functions of the lower 
motor neuron, with absence of sensory disturbance, point to the cerebral cor- 
tex. Wood, from experiments and investigations in canine chorea, located 
the disturbance in the spinal gray, but this disease is not identical with 
human chorea. 

Regarding the nature of the specific microbe in chorea, nothing defi- 
nite can now be offered. In 1891 Pianese 2 cultivated a rod-shaped 
microbe from the cord and brain of a fatal case of chorea, which, in- 
jected into animals, produced apathy, then tremor, then convulsive move- 
ments, and, finally, death. Autoptical search in these animals detected 
this bacillus exclusively in the nervous apparatus. This finding has not 
been confirmed. Dana 3 has found a diplococcus in the meninges of a 
fatal case, but as subacute leptomeningitis was present, it was possibly 
or probably the specific micrococcus of that disease. Various strepto- 
cocci have also been noted. Westphal, Wasserman, and Malkoff 4 
isolated from the blood, brain, and cardiac vegetation of a fatal case of 
chorea a micrococcus which produced arthritis in animals. 

Morbid Anatomy. — As chorea is seldom fatal, the post-mortem 
changes found in the extraordinarily severe cases that result in death 
can hardly be supposed to fairly represent the anatomy of the disease. 
Even in such cases there are no uniform or characteristic changes. In 
the brain and spinal cord intense hyperemia, peri-arterial exudations, 
minute hemorrhages, softened spots, and occasional emboli have been 
noted, especially in the deeper portions of the motor tracts in and about 
the basal ganglia. The chorea corpuscles, first described by Elischer, 
and often found by others, are equally developed in various infections, 
as proved by Manasse, who found them in twenty autopsies upon septic 
subjects, and was able to produce them in dogs by putrescent intra- 
venous injections. They are hyaline in chemical reaction, develop in 
and around the arterioles and in the perivascular spaces throughout the 
brain and cord, and furnish another argument for the infectious char- 

1 "British Med. Jour.," Sept, 19, 1896. 2 "La Riforma Med.," Julv 14, 1891. 

3 "Amer. Jour. Med. Sci.," Jan., 1894. 4 "Berlin, klin. Wocti.," No. 29, 1899. 



562 NEUROSES. 

acter of chorea." Turner 1 describes swellings and opacities in the corti- 
cal pyramidal cells. One of his five cases had puerperal sepsis and two 
albuminuria, both of which might account for the cellular changes. 
The two remaining cases, if identical, may be taken as showing changes 
of a septic or infectious nature. The heart is more often diseased in the 
fatal cases of chorea than in any other malady whatsoever. Osier, in 
the 73 cases collected by him, finds cardiac lesions recorded in over 90 
per cent., consisting of recent endocarditis, 62 cases, with pericarditis 
19 times; pericarditis alone iu 2 cases; chronic mitral endocarditis 
twice, and fatty heart once. The ordinary endocardial appearance is 
a row of papular granulations at the mitral orifice. All varieties 
of incidental and accidental septic conditions are reported in the 
literature. Staphylococcus aureus and pyogenes have been noted by 
Guizetti, staphylococcus aureus and streptococcus by Reichardt. Pre- 
oprajensky 2 claims to have found streptococci in the blood in two 
cases, both of which were benefited by the use of antistreptococcus 
serum. Benton and Walker 3 claim to have found a specific streptococ- 
cus in chorea and acute rheumatism reacting in certain respects differ- 
ently from the streptococcus of human septicemia. 

Symptoms. — Chorea is commonly of insidious onset, but its motor 
symptoms may appear abruptly — that is, within a few hours or days after 
a fright or other mental disturbance. In the large majority of cases 
parents can easily recall that for a period of days or weeks before motor 
disturbance attracted their attention the child had been peevish, obsti- 
nate, apprehensive, easily displeased, and less companionable with 
its playmates. Perverseness and moral obliquities sometimes appear. 
Very commonly the sleep has been disturbed and broken by distressing 
dreams or actual nocturnal pavor. More often there is mere restless- 
ness and difficulty in getting to sleep. This prodromic period should be 
carefully investigated, as it is likely to give valuable warning in case of 
recurrent attacks. At school the child becomes inattentive and forget- 
ful, and finds increasing difficulty with its studies. If reprimanded, 
there is undue depression or unusual emotion or capriciousness. The 
inability to study, due to the lack of mental concentration, leads too 
often to the supposition of overstudy ; but it is particularly among the 
bright, precocious, and easily stimulated school-children that chorea is 
likely to appear. These are exactly the children whose mental develop- 
ment should be retarded, and it is among these that forcing methods 
in school-work are most baneful. 

After a widely varying period the motor choreic features appear. 
These at first consist ordinarily of sudden, unwilled, slight movements 
or unexpected relaxation of muscular contraction. The child appears 
maladroit, upsets its cup, drops articles from its hands, and lays itself 
liable to admonition, and, unfortunately, in some instances, to chastise- 
ment, which may bring down the choreic storm in a burst of motor 
twitchings, grimacings, and spasmodic disturbance. Lacking cause of 
sudden exacerbation, the movements gradually become more pronounced 

1 "Path. Soc. Trans./' 1892, vol. xliii. 2 "La Sem. Med.," Dec. 10, 1902. 

3 "Brit. Med. Jour.," Jan. 31, 1903. 



IXFECTIOX NEUROSES. 563 

and bizarre. There is often complaint of fatigue, pains in the limbs or 
joints, and frequently loss of appetite and constipation are early noted. 

Motor Features. — The choreic movements ordinarily begin in the 
muscles of the hands and forearm, but the face is soon, sometimes first, 
affected, and then the lower extremities, shoulders, and trunk, in varying 
order. Occasionally, the chorea is confined to a single extremity or to 
one side of the body, or, beginning on one side, may invade the other, 
subsiding or persisting in the original territory. Commonly, both sides 
are not equally involved. As a rule, the affected muscles show three 
important functional modifications : (1) Unwilled but conscious twitch- 
ings or spasm ; (2) inability to maintain steady contraction, and (3) loss 
of power. The choreic movements vary not only in distribution, but in 
intensity at different times and in different cases. We may first consider 
a case of average severity. The spontaneous actions may be described 
as disordered, irregular, arrhythmic, of considerable amplitude, and of a 
rapidity between tics and athetosis. They cease during sleep, though 
there may be great restlessness. They may even prevent sleep. They 
can be slightly controlled during the execution of voluntary move- 
ments, but are excited and exaggerated by embarrassment and any 
emotional excitement. Mitchell and Rhein * define several varieties of 
choreic cases depending upon motor peculiarities : et (1) Cases which 
show, at some stage or throughout the attack, an absence of movements 
during rest. (2) Cases with continuous movements during rest, but 
increased by intentional effort. (3) Cases with severe choreic move- 
ments, entirely disappearing during muscular acts. (4) Cases in which 
the movements are unaltered by muscular efforts. (5) Cases presenting 
several of these phases at different times." In the face they usually 
cause bilateral grimacing, especially affecting the lips and nose, less 
frequently invading the muscles of the brow and eyelids. The lips 
may be quickly pursed up or retracted, the tongue protruded and re- 
tracted, the teeth snapped together. In this way speech is impaired and 
becomes halting or explosive, due entirely to faults of articulation, as 
the larynx is practically never involved. Sicalloicing is sometimes 
difficult, mainly, however, on account of the choreic movements of the 
lips, cheeks, tongue, and palate. The tongue is usually affected very 
early, and in perhaps the majority of cases the choreic movements per- 
sist in this organ after they have elsewhere disappeared. Ordinarily, 
if the patient is asked to show his tongue the chorea is at once provoked 
in the facial muscles, but the tongue, too, is animated by involuntary 
writhings that appear, subside, reappear, and usually end in its sudden 
retraction and the quick closing of the mouth. In very exceptional 
cases the ocular muscles are implicated, causing momentary diplopia, 
and movements in the iris have been seen attending momentary con- 
fusion of vision. Sluggishness of pupillary contraction to light is not 
uncommon, and a few cases of retinal embolism are recorded. 2 

In the upper extremities the choreic twitching is most and first devel- 
oped in the fingers, which move individually or together, separate and 
close, extend or flex, with more or less disorder. Pronation and supina- 

1 "Phila. Med. Jour.," Jan. 22, 1898. 

2 H. Thomas, "Johns Hopkins Hosp. Bull.," Oct., 1901. 



564 NEUROSES. 

tion are more common than wrist movements, and the shoulders are 
more affected than the elbows. Indeed, it is rare that shrugging of one 
or both shoulders does not take place. When the chorea is well marked, 
objects are grasped with difficulty. The hand approaches them by zig- 
zags and suddenly swoops down upon them. Finally, prehension may 
be impossible, and the patients can no longer feed themselves, or spill 
everything they attempt to carry to the mouth. The lower extremities 
are usually less affected, but, as in the upper members, the digits show 
the most disturbance, flexing, extending, or separating in disorder. The 
big toe and the thumb are most active, as a rule. The station is rendered 
unsteady, sometimes uncertain, and rarely impossible, by the movements 
of the legs and feet. In walking the gait is often peculiarly disturbed. 
The steps are unequal in length and irregular in rhythm. The feet may 
be jerked from the direct line of advance, raised too high, or brought 
down too vigorously, but never rhythmically. The knees are not always 
firmly supported, so that altogether there is sometimes presented a pecu- 
liar resemblance to the many-jointed action of marionettes danced on 
a string, which, taken with the grimaces and with the contortions of the 
hands, recalls the clownishness Sydenham so graphically described. 
The muscles of the trunk and neck do not escape, and may cause nod- 
dings and bendings that are often most apparent when the patient is 
seated. The diaphragm and the thoracic, muscles are commonly invaded, 
causing irregularity of respiration and sometimes spasmodic noises, or 
there may be peculiar involuntary clucking or swallowing sounds. 
Graves 1 has made a painstaking study of these respiratory irregulari- 
ties which, by suitable self-registering apparatus, he finds practically 
always present, even in the very mild cases, and, what is a matter of 
more importance, that they persist long after the more noticeable symp- 
toms disappear. In this way many recurrences are shown to be merely 
relapses of the. original attack. The choreic movements may be so 
continuous and severe as to prevent sleep, to confine the patient to bed, 
and to cause innumerable bruises and excoriations by friction or by 
rough contact with hard substances, such as the w r alls and furniture. 

If the patient is directed to grasp the physician's hand and hold 
firmly, inequalities in pressure will at once be observed. Eelaxation or 
sudden increase of muscular tension, or both, are noticed. Of still 
greater importance is a loss of muscular power, which is practically always 
present in muscles affected by chorea, as can be clearly shown in the 
unilateral cases. This may reach a loss of fifty or seventy per cent., and 
in the paralytic form of chorea it constitutes the major motor difficulty. 
The paretic feature of chorea explains the ready fatigue and accentuates 
the need of rest in the management of the disorder. Russel 2 notes 
that the handwriting may be (1) merely choreic, (2) may be very good 
even when choreic disturbance is well marked, (3) may be almost im- 
possible though choreic movements are extremely slight, (4) may be 
entirely unintelligible though control of the pen is good, and (5) may 
present pure motor agraphia. 

The sphincters are never affected except in the last stages of the fatal 
cases. Objectively, sensibility 'is normal, as a rule, and any considerable 
1 "Jour. A. M. A.," Jan. 30, 1909. 2 "Lancet," April 1, 1899. 



INFECTION NEUROSES 565 

anesthesia or dysesthesia should cause a suspicion of hysteria. Triboulet 
laid much importance on sensitive spots beside the spinal processes of 
the vertebrae and over the intercostal nerves, but they are inconstant. 
The electric excitability of the nerves and muscles is sometimes increased, 
and the anodal closing contraction may equal the similar cathodal re- 
sponse. General loss of flesh is common, but localized muscular atrophy 
is very seldom found. Shaw l calls attention to a jerky response upon 
eliciting the knee phenomenon, otherwise the reflexes are unaffected. 

Mental Disturbances. — Aside from the temperamental, moral, and 
affective changes so common in the prodromal stages, and which may per- 
sist throughout the attack, other mental disturbances may rarely occur. 
The former are, in a sense, proper to chorea, and with the myasthenia 
may cause a marked change in the fades, which presents an inane and 
stupid appearance, often at great variance with the normal attributes of 
the child. Some of this may be due to the weakness of the facial mus- 
cles, but mainly it is consistent with the hebetude, irritability, and 
weakened mentality in such cases. Hallucinations of sight are frequently, 
and of the other senses rarely, noted. They usually appear toward or 
during the night. In the grave cases, when the choreic status is produced, 
the temperature elevated, and the muscular activity at its height, delirium, 
commonly of a hallucinatory character, is often present. Occasionally, 
psychoses of various forms are encountered — the concomitant manifesta- 
tions of degeneracy and toxicity. 

Cardiac Disorders. — In chorea the heart frequently presents clinical 
symptoms, and apparently is much oftener involved than auscultation 
indicates. This is shown by the considerable percentage of cardiac 
lesions in fatal cases without cardiac symptoms, and the astonishing 
number of cases of chorea which show organic heart-lesions upon 
examination years after the chorea has disappeared. During chorea 
heart-murmurs are present in about one-third of the cases, and are func- 
tional or organic. In addition, there are disturbances of rhythm, rapid 
action, and pain. Galdi 2 calls particular attention to the variability of 
the cardiac diameters during chorea and their wide and rapid changes 
under insignificant causes. 

Functional murmurs are most commonly heard at the base and to the 
left of the sternum, with the systole usually most intense over the pul- 
monary valves, and often attended by rapid heart-action. Anemic 
murmurs over the tricuspids propagated into the neck are not infre- 
quent, and are often associated with an increased area of cardiac 
dullness. They may only be noticeable with the patient in the horizontal 
position. Organic murmurs are usually the result of endocarditis, most 
often affecting the mitral orifice, systolic in point of time, and with 
greatest apical intensity. Palpitation and cardiac or precordial pain are, 
on the whole, exceptional. An altered rhythm is a very common observa- 
tion in chorea. This has been attributed to chorea affecting the heart- 
muscle, but is more reasonably referable to functional disturbance and 
respiratory irregularities, which are very frequent in this disease. Very 
often the frequency of the heart-beats is the same in both the horizontal 
and vertical positions. A rapid heart sometimes persists after the attack. 

1 "Albany Med. Ann.," May, 1897. 2 "II Policlinico," Nov. 21, 1903. 



566 NEUROSES. 

Ordinarily, the endocarditis develops during the evolution of the chorea, 
and is sometimes attended by joint symptoms. Organic heart disease 
seems to be most frequent from five to ten years of age, but this corre- 
sponds to the period of the greatest frequency of chorea. The customary 
post-mortem findings have been already noted. Of equal or greater 
importance are the postchoreic observations. Thus, Mackenzie found 
6Q.Q per cent, of thirty-one cases of chorea examined from one to five 
years after the attack marked by organic cardiac lesions. Osier, in a 
more extended and very closely scrutinized series, found 51^ per cent, 
of postchoreic cardiopaths. The same thing is shown by the long- 
recognized fact of an increasing proportion of cardiac diseases in the 
subjects of repeated attacks of chorea. The practical deduction points 
the need of systematically watching the heart throughout the course of, 
and for a long time subsequent to, the attack of chorea. 

The general state in chorea is commonly reduced. Often, but 
by no means always, there is some degree of physical depression pre- 
vious to the onset. Anemia, loss of appetite, gastric indigestion, slug- 
gishness of the bowels, and dryness of the skin are usually developed 
early in the choreic attack, and are sometimes induced or increased by 
the injudicious use of arsenic. Ordinarily, chorea is afebrile. In the 
choreic status and in cases of mixed infection or concomitant sepsis, 
the temperature rises and is proportionate to its cause. 

Course. — The course of chorea, whether of insidious or of abrupt 
onset, is usually marked by exacerbations and remissions of the peculiar 
movements. In the majority of cases, after reaching various grades of 
severity, the chorea gradually declines, leaving the lower extremities, the 
upper extremities, the trunk, the face, and the tongue, usually in the 
order mentioned. At a time when the movements no longer occur 
spontaneously they may still be provoked in the face, and especially in 
the tongue, by directing it to be vigorously protruded. The average 
duration of the disease is from six weeks to four months, but cases lasting 
two weeks or less and others lasting six to eighteen months are not very 
rare. The common termination of chorea is in complete recovery, though 
death occurs in rare instances. A fatal termination results in the very 
severe cases in which the choreic status exhausts the patient, or more 
frequently from complications, especially on the part of the heart. Cere- 
bral hemorrhage and softening and concurrent infections may lead to a 
fatal termination. In other and also very exceptional cases the chorea 
becomes chronic. It may also be followed by a habit spasm or tic. 

Recurrence in chorea is so common that it is always to be expected, 
and occurs in over one-third of all cases. Up to the third attack both 
sexes show their usual relative susceptibility, but beyond that number 
the proportion of girls and women rapidly advances in the lists. It is 
rare to find a male presenting more than 3 attacks, but 10, 12, and 
more attacks in females are not very rare. Some patients present 
chorea every spring for several years. As a rule, succeeding attacks 
grow progressively shorter. See gives the average duration as 139, 80, 
and 55 days in the first three attacks, respectively. It is to be doubted 
that some of the alleged repeated attacks are such in fact. In many 
instances a close examination of the patient in the interval will enable 



INFECTION NEUROSES. 567 

the observer to evoke choreic traces in the face, tongue, and extremi- 
ties, though parents, teachers, and patients insist that complete recovery 
has taken place. In such instances a recurrence, strictly speaking, is 
an exacerbation. Choreic girls are also later liable to gestational chorea. 

Forms. — Sydenham's chorea presents several forms or modifications 
that require individual mention. We may distinguish the common 
form, which has been the basis of the above description ; the grave form, 
the gestational and the paralytic forms. 

The grave form, chorea gravis, is marked by an intensification of 
all the motor and usually of the mental manifestations of ordinary 
chorea. It is ordinarily of acute and intense onset, or may occur as a 
sudden recurrence or intense exacerbation of the common type. The 
choreic movements are wide-spread, continuous, and violent. They may 
disturb sleep, or prevent it altogether. The patient usually is unable 
to stand or to sit on a chair, and may be so violently agitated as to be 
thrown about and off the bed. Swallowing and speech are interfered 
with or rendered impossible. Excoriations, bruises, and other injuries 
result. Infections may thus occur, inducing suppurations and erysipelas. 
Fever arises ; there is delirium, sometimes of maniacal intensity. Such 
a continued, exalted, intensified, chorea has been denominated the choreic 
status. The choreic state, thus constituted, persists for days, and finally 
subsides, death often following coma. It differs only in degree from 
the milder attacks, and all gradations may be encountered. Mental dis- 
turbance at intervals, or more or less continuous, may be encountered, 
varying between mild momentary delirium and wild mania. Delusions 
and hallucinations are not uncommon in this phase of mental disorder and 
may be presented side by side with an appearance of fairly good mental 
balance and self-control. The maniacal cases usually terminate fatally. 

The chorea of pregnancy, chorea gravidarum, usually appears in young 
primiparse, commonly during the first half of pregnancy, and is fre- 
quently preceded by a history of chorea in earlier life. The predisposing 
and exciting causes of the common form also obtain here, and the symp- 
tomatology is much the same. Cardiac complications are the rule. The 
motor agitation is usually intense, and there is commonly involvement 
of the pharyngeal and respiratory apparatus, less often of the laryngeal 
mechanism. Abdominal and vaginal palpation usually intensify the 
choreic trouble, and the fetal movements sometimes have the same result. 
Mental disturbance and affective changes are nearly always present, 
and tend to persist after parturition or may only develop post partum. 
Parturition may diminish, augment, or fail to affect the chorea, but, on 
the other hand, the chorea may cause premature birth and abortion. 
Ordinarily, chorea, once established, persists until the womb is evacu- 
ated and mas r continue during lactation. It is much more serious than 
the ordinary form, and terminates fatally in about twenty per cent, of 
all cases. In some patients it recurs at each subsequent pregnancy. 

Paralytic chorea, called limp chorea by English writers, is probably 
more frequent than reports would indicate. The paretic element in 
chorea has been particularly insisted upon. In this form it is the dom- 
inant condition, and the choreic movements are insignificant. It has 
a predilection for young children, and is most frequent at about six or 



568 NEUROSES. 

seven years of age. Commonly, some infectious malady seems to act 
as a provoking cause or complication. The premonitory stage corre- 
sponds to that of the ordinary type. Ordinarily, the paresis appears early 
and may or may not be preceded by choreic twitching. A mono- 
plegia hemiplegia or paraplegic distribution may be presented, but 
monoparesis is most common. The muscles are toneless and the reflexes 
abolished. There is, however, no reaction of degeneration, and the 
outcome is usually complete recovery within a few weeks or months. 
Muscular atrophy sometimes is noted. It is not unlikely that some 
cases brought under this head really belong to the neuritides, or to 
myelitis, or are combinations of these with chorea. 

Diagnosis. — The diagnosis of chorea is extremely simple when the 
motor symptoms are once developed. Difficulty arises usually through 
mistaking symptomatic choreoid movements in other diseases for true 
chorea. The escort of attending symptoms should differentiate these 
pseudochoreas. Here may be mentioned the rhythmic tremblings of 
metallic and toxic poisoning, of hysteria, and of multiple sclerosis. 
Friedreich's ataxia, athetosis, and posthemiplegic chorea have their cerebral 
signs. Tics are more sudden and more completely expressional or 
gesticulatory in character, showing their subconscious, purposive basis. 
Huntington's chorea almost invariably has a familial history, comes on 
after adult years, and is attended by progressive dementia. The 
myoclonias and the so-called electrical choreas present only a superficial 
resemblance to the chorea of Sydenham. The premonitory symptoms 
for a given case having been made out, their reappearance often enables 
the early diagnosis of recurrent attacks before motor symptoms attain 
prominence. 

Prognosis. — In the great majority of cases chorea may be con- 
sidered a self-limited disease of favorable prognosis. Complete recovery 
is the rule in children under ten years of age. In proportion as puberty 
is reached and adult years attained, the prognosis becomes more guarded 
both as to immediate results and the establishment of chronicity. Recur- 
rent attacks, however, have a progressive tendency to earlier recovery. 
In a given case the intensity of the attack, the violence of the choreic 
motions, their generalization, the evidence of degeneracy in the indi- 
vidual, and a bad general physical state unfavorably modify the outlook 
for early recovery. The prognosis is also affected by the presence or 
development of cardiac involvement or the appearance of septic pro- 
cesses and high temperatures. The choreic status is of very grave 
significance, and usually terminates in death. Chorea in pregnancy also 
furnishes a high mortality for the mother and more often destroys the 
fetus. 

Treatment. — In the treatment of chorea the constant evidence of 
muscular weakness and mental enfeeblement calls in decided tones for 
rest. Any emotional disturbance promptly aggravates the choreic 
movements. The child in ordinary cases must be taken from school 
and kept apart from the romps and often from the gibes of its play- 
mates, and for the most part in bed. A little chloral to induce sleep, 
and frequent sponge-baths, gentle massage, and pleasant, quiet diversion 
will often, with rest, work great improvement in a few days. Tonics, 



INFECTION NEUROSES. 569 

especially iron, are usually indicated, and attention to the constipation is 
always in order. The diet should be nutritious and easily assimilated, 
and contain plenty of fat in the form of cream and butter. It should 
be carefully controlled, as choreics are very prone to crave indigestible 
and objectionable articles. The use of drugs is of secondary importance. 
Arsenic, once in vogue, is valuable as a tonic in small doses, but usually 
harmful in large ones and only rarely efficacious against the chorea 
when pushed to the utmost limit of toleration. It is capable of pro- 
ducing all sorts of intestinal disturbance, and its protracted use may 
induce pigmentary changes in the skin or cause a multiple peripheral 
neuritis. It must, however, be admitted that in some cases a short, 
vigorous course of arsenic reaching ten to fifteen drops of Fowler' s 
solution, three times daily, for a child six or seven years old, sometimes 
acts favorably. It may be commenced with a single drop and increased 
one drop a dose until the stomach rebels, which is usually at about twelve 
drops. It should then be stopped for a day and renewed at the final 
dose and slowly increased. It can rarely be used more than three 
weeks at a time with advantage. The use of quinin in large doses, as 
suggested by Wood, has in a series of cases in the writer's clinic failed 
to prove of any value. 

In the severe cases absolute quiet and rest in bed or in a padded 
corner on the floor is required. Food must sometimes be given by the 
nasal or rectal tube and chloral must be used freely, associated with 
bromid if there is much delirium. Even morphin may be required, 
and strychnin to maintain the heart. Sulphonal, trional, exalgin, and 
antipyrin have given help in some such cases. Small doses of apomorphin 
from the one two-hundredth to the one-twentieth by mouth or hypoder- 
matic method, depending upon the severity of the case and the age of 
the patient, have been strongly recommended. 1 Hot baths and cold 
packs often are of distinct service. The conservation of strength and 
the support of the physical forces require most careful thought. 

In the chorea of pregnancy it is seldom needful to terminate gestation, 
but if the motor storm is very violent and the mental features pro- 
nounced, or the physical state low, it may be indicated, especially as 
amelioration sometimes follows spontaneous abortion or delivery at 
term. Marinesco 2 recommends the intraspinal injection of from 3 to 5 
c.c. of a 25 per cent, solution of magnesium sulphate in very severe 
and even in the pregnancy cases of chorea, to control the choreic motil- 
ity. An antistreptococcus serum therapy has also found advocates. 3 

Complications, such as phlegmons, joint disease, and cardiac involve- 
ment, must be met on their indications. Recurrences should be anticipated 
and the parents should be taught the significance of sleeplessness, irri- 
tability, fidgetiness, capriciousness of conduct and appetite, and at once 
resume proper treatment. In girls this is particularly needed. In the 
pubescent period and later gestational experience, watchfulness should 
be exercised to maintain both the general health and the bod/-weight at 
a proper level. 

1 Tull, "N. Y. Med. Jour.," March 14, 1895. 

2 "Sem. med.," 1908. 3 Mayrj "wien. med. Woch.," 1909. 



570 NEUROSES. 

CHAPTER III. 

MOTOR NEUROSES* 

The neuroses brought under the above heading have, in common, a 
preponderance of motor symptoms. Their grouping is entirely arbi- 
trary and one of convenience. 

HUNTINGTON'S DISEASE. 

In 1872 Huntington called marked attention to a number of families 
living in southeastern New York, who had for many years been under 
the continuous observation of his father and grandfather, both medical 
men. These people were afflicted with a family disease locally known 
as " megrims " or " megrums," and, owing to their peculiar motor diffi- 
culties, the patients were commonly called " shakers." The disease has 
been recognized in many parts of the world, and is variously denomi- 
nated Huntington's chorea, chorea of the aged, family chorea, adult heredi- 
tary chorea, chronic chorea, and chronic progressive chorea. As early as 
1850 See and Sanders described the condition under the name of chronic 
progressive chorea. 1 As it has no well-founded relation to Sydenham's 
chorea, the term Huntington's disease is here adopted as open to the 
least objection. The disorder presents an insidious onset in adult life, 
a marked hereditary character, and a w T ell-defined tendency to mental 
deterioration and dementia. 

Etiology. — The salient etiological feature of Huntington's disease 
is its heredity. It has been traced through five generations, and in a 
given family marks more victims than any other familial disorder, 
sometimes affecting as many as half of the entire number. It is trans- 
mitted about equally by males and females, but presents the peculiarity 
of never reappearing after once the hereditary chain is broken. Thus 
it never skips a generation. In contrast to true chorea it affects the 
male sex in greater proportion. Huet collected a series of cases em- 
bracing forty-four men and thirty-six women. It is also at variance 
with chorea in the factor of age. It usually appears from thirty to 
forty-five, but may develop at any later period. Exceptionally, it has 
been noted at puberty, never in childhood or infancy. Again, rheuma- 
tism in the personal and family antecedents is rare. In some instances 
fright or other mental trauma has appeared to induce it. Epilepsy is 
sometimes associated with it. 

Morbid Anatomy. — It may be stated that no characteristic changes 
are recorded in the cases examined post mortem. They are those common 
to dementia in general. Thus Lannois and Paviot 2 in two cases found 
meningeal thickening, pachymeningitis, cerebral atrophy and compensa- 
tory hydrocephalus. The descending cord-tracts and the anterolateral 
and cerebellar tracts were slightly sclerotic. The cortical layers pre- 
sented a round-cell infiltration. C. A. Good 3 and Kattwinkel have 
found in well-examined cases no evidence of inflammation, but wide- 

1 "Archiv. f. Psychiatrie," Bd. 2, S. 226. 2 "Arch, de Neurol.," Oct., 1897. 

3 "Amer. Jour, of Insanity," July, 1900. 



MOTOR NEUROSES. 571 

spread degenerative cellular changes throughout the cortex, most 
marked, however, in the frontal regions. Margulis 1 in 2 cases found 
great proliferation of neuroglia throughout the brain and cord, and feels 
justified in calling the disease a congenital chronic degenerative gliosis. He 
finds the cellular structures secondarily strangled by the proliferating glia. 

Symptoms. — The motor symptoms commonly appear insidiously, 
but in some cases mental enfeeblement precedes. The face, the speech, 
or the gait may be first involved. Slow involuntary contractions 
modify the facial expression, cause a hand to start, a finger to move, or 
compel the feet to deviate from the intended direction. These motions 
at first are temporarily controllable, or cease on brief voluntary effort. 
Later, they are not under such control. The gait becomes progressively 
more erratic and uncertain, until, finally, it closely resembles that of 
drunkenness with the addition of gesticulatory movements of the arms 
and of facial contortions. The peculiar gestures, poses, and exaggera- 
tions of action in these cases are very prominent and often strangely 
at variance with the mental emotions actually in play. They are 
increased by embarrassment and emotion, but lessen in repose and sub- 
side during sleep. Though bearing a rough resemblance to the move- 
ments of chorea, they are more deliberate, gesticulatory, and of greater 
range. There is usually some muscular weakness, but no other modifi- 
cation of energy and none of sensation. Speech is thickened, drawling, 
and infiltrated with ha's and hem's, but not staccato or explosive, and 
may finally become impossible. In advanced cases the patient may be- 
come bedridden. 

The mental state is one of progressive enfeeblement and depression. 
It is of slow onset and its natural goal is complete dementia. It may 
precede the motor symptoms, but usually follows them at a varying 
period. Thereafter the muscular and mental disability increase together 
to the end of life. A duration of ten to thirty years is common and old 
age is often attained. Recoveries are unknown. 

Diagnosis. — Huntington's disease encountered in a number of 
generations can offer no diagnostic difficulty. Originating de novo, it 
must be distinguished from chorea proper, from the maladie des tics, 
from double athetosis, and from the family ataxias. Chorea has its 
early mental symptoms, its cardiac lesions, its tendency to recover, and 
an absence of extreme mental degradation. Tics have a limited distri- 
bution, are much quicker in their rhythm or activity, and present no 
dementia unless occurring in idiocy. Athetosis is congenital, infantile, 
or postparalytic in development. The family ataxias have their eye 
symptoms, lack mental degeneracy, and commonly appear early in life. 

Treatment has been futile. 

MYOCLONIA. 

The term myoclonus or paramyoclonus has been used to designate in- 
voluntary, unsystematized, arrhythmic, quick, muscular contractions, 
similar to those produced by an electric shock. They may be localized or 
disseminated and may embrace a muscle, a muscle group, or only a few 
muscular fibers. Under the general term myoclonia may be embraced 
1 "Deutsch. Zeit. f. Nervenheilk.," Feb., 1914. 



572 . NEUROSES. 

the paramyoclonus multiplex of Friedreich, the electric chorea of Bergeron, 
Henoch, Paget, and the fibrillary chorea of Morvan. Senile chorea, so 
called, is generally but the motor index of cortical degenerative changes. 
Myoclonia is sometimes combined with epilepsy, furnishing the " asso- 
ciation disease " of myoclonus-epilepsy, to be described with epilepsy. 

Etiology. — Practically nothing is known of the causation of myo- 
clonia. Lundborg 1 has suggested that it bears some relation to the 
thyroid. Nervous heredity is commonly encountered, the male sex pre- 
ponderates, and adult age is the usual epoch, though Bergeron's form is 
most common in children. Overwork, fatigue, hunger, fear, traumatism, 
and cold have been considered excitants. 

The nature of the disease is speculative, but the motor cells in cortex 
and cord are presumed to be at fault. A case in which muscular 
atrophy followed is thought to add force to this point of view so far as 
it relates to the cord. The morbid anatomy is practically unknown. 
Murri 2 found a chronic localized pachymeningitis Avith atrophy of the 
central cortex in one case. 

Symptoms. — The onset may be sudden, following one of the in- 
citing causes mentioned, or the motor symptoms may insidiously develop. 
These are the essential features of the disease, which lacks sensory, 
trophic, dynamic, and electrical symptoms but usually presents increased 
tendon reflexes. The clonic contractions begin ordinarily in the lower 
extremities, and, as a rule, are bilateral, though not strictly symmetrical. 
They then involve the upper limbs, but commonly spare the face. The 
clonic contractions are instantaneous and involuntary, increased by 
emotion, but subject to some degree of voluntary control. They subside 
or remain in abeyance during voluntary use of the given muscles, at 
least for a few minutes. Depending upon their location, extent, and 
intensity, they may appear only as a contracting muscular bundle, pro- 
ducing a linear elevation of the skin, or may cause a joint, a digit, or 
an entire extremity to start suddenly. Usually clonic, they may be 
repeated so rapidly as to produce a tonic, or even tetanic effect. One 
or all varieties may be observed in the same patient. The contractions 
are unequal, irregular, and arrhythmic. Sometimes they produce con- 
stant agitation ; sometimes they come on in little attacks, with varying 
intervals of quiet. They may reach a rate of 60 to 100 a minute, and, 
as a rule, are more rapid the smaller the muscle affected. They cease 
during sleep, but in some instances may rouse the patient in the night. 
Percussion, pinching, heat or cold, electric shocks, and the emotions tend 
to augment and recall them. The intellect is unaffected. The face, 
tongue, and trunk are exceptionally involved. The muscles of organic 
life and the sphincters escape. 

When the disease begins insidiously, the contractions come on during 
repose and at long intervals, attracting little attention. They progress- 
ively increase in extent and vigor, and in a few weeks or months reach 
the period of complete development, which varies in duration in different 
cases, but is usually protracted many months. The tendency of the dis- 
ease is then to subside slowly toward complete recovery, but often with 
remissions or later recurrence. Most cases finally recover. 

1 "Hygeia," 1900. 2 "Arch. Ital. di Biol.," 1901. 



MOTOR NEUROSES. 573 

Diagnosis. — The diagnosis, owing to the rarity of the affection, is 
seldom made. Tics are likely to be mistaken for myoclonia unless the 
case is carefully studied. These, however, are almost invariably first 
unilateral, and have a predilection for the face, whence they usually 
spread to the neck, arms, etc. They are distinctly purposive in char- 
acter, and expressive or gesticulatory, demonstrating the subconscious 
basis on which they develop. Jacksonian fits are usually attended by 
sensory aura?, mental disturbance, and major convulsions at some period 
of the disorder. 

The prognosis is good. 

Treatment has appeared to have little effect. The use of galvan- 
ism to spine and muscles is favored by some, and motor inhibitors, such 
as atropin, eserin, valerian, hyoscin, and cocain, have been employed 
with varying results. Commonly, the general physical condition requires 
appropriate attention. 

DUBININS DISEASE. 

In 1845 Dubini described a disease occurring in the malarial 
regions of Italy which he called electrical chorea. The name is unfor- 
tunate, as the condition is not allied to Sydenham's chorea, nor does it 
resemble it in any manner. This name has also been applied to several 
varieties of myclonus, and to some hysterical manifestations, with equal 
disadvantage. The morbid anatomy is not yet determined, though many 
of these cases have been examined post mortem. In nearly all there is 
evidence of infection, such as pulmonary and splenic congestion, inflam- 
mation of the meninges, increase of cerebrospinal fluid, cerebral con- 
gestion, especially at the base, and softened foci in the cortex and 
great ganglia. In some earlier instances the cerebrospinal axis was re- 
ported of normal appearance. This statement may be received with 
some doubt. The disease has been attributed to everything, from malaria 
to typhus, and seems to be confined to Italy, and especially to Lombardy. 

The onset is abrupt and marked by intense, continuous pains in the 
head, neck, and sometimes in the lumbar region. Shortly the extremi- 
ties are seized with short, sharp spasms, recalling the electrical 
responses, and giving rise to the name " electrical chorea." They usu- 
ally first appear in the upper extremities, especially in the hands and 
fingers, sometimes in the face, and are attended by painful sensations in 
the same locality. Gradually they spread into a hemiplegic or diplegic 
distribution, which is attained within a week or two. The twitchings 
occur at somewhat regular intervals, and frequently are accompanied by 
epileptoid convulsions, without loss of consciousness, which may take 
place several times in the twenty-four hours, and commonly leave 
paretic traces behind them. Sensibility is not greatly affected, though 
sometimes hypersensitiveness may be easily provoked and exalts the 
motor symptoms. Electrical reactions are said to be normal. 

The disease usually grows progressively worse. The muscular spasms 
become almost continuous, the convulsions are rapidly repeated, and in 
from ten to one hundred and fifty days the disease ends in death in 
about ninety per cent, of all cases. The fatal termination is preceded 
by a condition of continuous epileptoid spasm, a sort of status, followed 



574 NEUROSES. 

by coma, relaxation, and fatal exhaustion. Occasionally, there are re- 
missions in the progress of the disease. Treatment has been unavailing. 

PARKINSON'S DISEASE, PARALYSIS AGITANS. 

In 1817 Parkinson gave a complete clinical description of a rather 
common disease, which he termed shaking palsy. It is generally known 
as paralysis agitans. As the usual weakness may be absent and the 
tremor may appear only late in the disease, the descriptive name is not 
always applicable. Generally, it is considered a neurosis, but accumu- 
lating material points to an organic basis for the malady, which will 
probably soon pass into its proper category. The disease is one of late 
middle life, usually commencing locally, tending to hemiplegic and 
finally to diplegic distribution, and commonly marked by rigidity, 
tremor, and weakness of similar extent. Never fatal in itself, it lasts 
until death. 

Etiology. — Parkinson's disease rarely commences before forty or 
after sixty-five years of age. Most commonly it appears at about fifty. 
That it is not essentially a senile disease is clearly shown by Willige, 1 
who collated from the literature 47 cases under thirty years of age and a 
group of 12 under twenty. The male sex furnishes over two-thirds of 
all cases, and this proportion is uniform for all ages. A neuropathic 
heredity is commonly encountered. In exceptional instances the disease 
appears in several generations or in collateral family branches. Lund- 
borg 2 has recorded 5 cases in one family, several other members being 
affected with myoclonia, both of which diseases he thinks related to 
disorders of thyroidal action. In another case he saw Parkinson's 
disease with myxedema. Fraenkel 3 has also called attention to myxede- 
matous areas in paralysis agitans which are suggestive of a glandular 
factor. Among the alleged exciting causes, fear, anxiety, grief, and 
physical exhaustion have been named. In Paris and Strasburg during 
the sieges of the Franco-Prussian War and in the American Rebellion 
numerous cases developed under the combined influences of privation, 
prolonged anxiety, and sudden fears. Traumatism has appeared to 
incite it, and in such instances the tremor has sometimes appeared in 
the limb affected, sometimes even in the part of the limb directly injured. 
Krafft-Ebing 4 traced the disorder to trauma in 7 out of 110 cases. The 
possibility of hysteria in such cases is strong. Mental shock cannot 
be excluded in such accidents. 

Morbid Anatomy. — Regarding the morbid anatomy of Parkinson's 
disease there is much diversity of opinion and observation. In typical 
cases Westphal, Berger, Charcot, and Gowers have found no abnor- 
malities. Others have found changes in the encephalon, cord, and even 
in the muscles. Dubief and Ketscher have noted retrograde changes 
in the motor cells of the anterior horns and sclerous changes in the 
white tracts of the cord, recalling those due to senility. Redlich 5 in 
seven cases found the cord most affected. Small patches of sclerosis 
were found, mainly in the posterior columns, but some in the lateral 
tracts, and most frequently at the level of the cervical and lumbar 
enlargements. They originated from the vessels, and showed atrophy 

1 "Zeitschr. f. d. ges. Neur. und Psych.," 1911. 2 "Hygeia," 1900. 
3 "Deut. Zeit. f. Nervenh.," April, 1899. 4 "Wien. klin. Woch.," 1899. 

5 "Centralbl. f. aUge. Path.," Nov. 4, 1894. 



MOTOR NEUROSES. 



575 



of nerve-fibers and increase in interstitial tissue. The process was an 
endo- or peri-arteritis, with extension to the surrounding parts. The 
cells of the anterior gray and Clarke's columns were almost always 
pigmented. He recognized the changes as senile in part, but thinks 
they exceed it in degree. Dana has described a diffuse sclerous myelitis 
with vascular lesions and cellular atrophy in both cord and cortex. 
Mendel, Charcot, Bloch, and Marinesco in three cases have found 
tubercles in the peduncular region, and Brissaud, from a study of 
pseudobulbar palsies in connection with paralysis agitans, is inclined to 
locate the lesion in the peduncular territory. The monoplegic and 
hemiplegic cases indicate cerebral disorder and the involvement of the 
face- and jaw-muscles is certainly due to supracordal 
states. Gordinier 1 has collated 24 cases examined 
by recent methods. In all there was decided uni- 
formity of anatomical findings. These involved 
blood-vessels, neuroglia, and nerve-cells. There was 
proliferation of nuclei and thickening of vascular 
walls, increase of neuroglia about the blood-vessels, 
and patches of perivascular sclerosis, with pigmen- 
tation, degeneration, and atrophy of nerve-cells and 
nerve-fibers. The spinal cord was most affected, 
the changes being most marked in the gray matter 
and posterolateral portions of the lumbar and cer- 
vical enlargements, usually decreasing brainward, 
and sometimes not appearing in the encephalon. 
Though resembling senile changes, the lesions were 
more intense and general arteriosclerosis was usu- 
ally absent. At present we can go no further than 
the supposition that vascular faults are primary, the 
neuroglia and cellular structures being secondarily 
involved in degenerative changes. Fattv changes in 
the muscles are encountered in very old cases, and 
sometimes a peripheral nerve degeneration of a 
slight degree. Schiefferdecker and Schultze 2 find the muscle fibers, 
fibrillar and nerve spindles diseased, but no change in the nerves. 
Catola 3 has described changes in the muscles indicating a toxic chronic 
nodular myositis, and occasionally patients do complain of tender mus- 
cular thickenings. C. D. Camp 4 calls prominent attention to the para- 
thyroids and suggests that their disease gives rise to the muscle changes 
through an auto-toxic effect. In 1897 the author treated many cases with 
desiccated parathyroids prepared in the Armour Laboratory, but without 
appreciable benefit. 

Symptoms. — A typical case of Parkinson's disease presents a most 
striking picture. The patient trots into the room with short, reluctant 
steps, apparently following his center of gravity. The body is inclined 
forward, the neck extended and rigid, the elbows flexed and slightly 
abducted, bringing the hands, with their trembling fingers, to the level 
of the groins. The face is mask-like, the eyes bright and unwinking. 

1 "Amer. Jour. Med. Sci. ." Dec, 1899. 2 "Deut. Zeit. f. Nervenheilk.," Dec, 1903. 

3 "Riv. dipathologianerv. e ment.," 1906. i "Jour. A. M. A.," April 13, 1907. 




Fig. 234.— Parkinson's 
disease. Attitude. 



576 



XEU ROSES. 



The patient turns bodily, deliberately, and rigidly. He sits down slowly, 
with precaution, on the edge of the chair, always leaning forward, his 
shaking hands on his knees in constant motion. In the more advanced 
cases the patient drops rigidly into the chair. Every change of position 
is studied and reluctant. We may take up the symptoms in detail. 

The muscular rigidity is worthy of first" attention, as it is the 
dominant motor phenomenon, causing the peculiar attitudes and pos- 
tures, the immobile face, and the slowness of movement. It is the motor 
analogue of the mental inertia so common in this disease. It is nearly 
always present where the tremor exists, and may be highly developed 
without the tremor, or may first invade the parts that subsequently 





Fig. 235. — Sitting attitude in paralysis 
agitans. 



Fig. 236.— Parkinson's disease : facies. 



tremble. Owing to the rigidity, the reaction-time is much increased. 
Dyleff 1 calls specific attention to the fact that, while voluntary active 
movements are generally weak, the subjects of Parkinson's disease can 
oppose passive movements with practically normal strength, but passive 
motion is also sometimes impeded by the rigidity. There is some 
hypertonus, and the tendon reflexes are usually slightly increased. 
A foot-clonus is never encountered. There is a characteristic facies. 
The nasolabial folds and lines of expression tend to disappear. 

The face becomes smooth. The brow may 
^^ retain its cross- wrinkles through enforced 

w **> > elevation requisite for forward vision, if 

the body and head be bowed. The eyes 
are widely opened and rarely wink. The 
ocular globes tend to remain fixed so that 
the patient, in order to change the direction 
of vision, ordinarily turns bodily with the 
neck held rigid. Movements of ocular 
association and accommodation are im- 
peded by this rigidity, and the patient 
shows little or no facial variation for any 
of the emotions that may play behind this 
mask. Speech is modified. It becomes 
monotonous and deliberate. The patient 
K'L'Encephale," 1909. 




Fig. 237.— Gait in paralysis agitans, 
showing propulsion. 



MOTOR NEUROSES. 577 

hesitates, but, once started, hurries his sentences and stops abruptly as 
if relieved to be through. He likes monosyllables and may become ex- 
tremely taciturn. In some cases tremor and rigidity of the vocal cords 
have been observed by means of the laryngoscope. In some instances 
there is an excessive secretion of saliva. In others true bulbar symptoms 
are added with indications of labioglossolaryngeal palsy. 1 

In the neck all the muscles are involved, giving an appearance of 
stiff-neck or rheumatic torticollis, but the face is always held to the 
middle line, the chin commonly somewhat advanced. The body is bent 
forward throughout its length and also at the hips. There is every- 
where a preponderance of flexor positions, as a rule, but in very excep- 
tional cases the neck and body may be bent backward. The arms, 
naturally drooping forward, are flexed at the elbows, which are slightly 
separated from the sides. The hands may be partly flexed or ex- 
tended at the wrist, but the fingers are always held more or less in 
flexion. A position similar to that of holding a pen is common, or the 
hand may be partially closed. The digits frequently deviate to the 
ulnar side of the hand, as in rheumatoid conditions, and these may also 
be present. In the lower extremity the stiffness is less marked, but in 
advanced cases causes a knee-sprung attitude and gait. 

The gait of Parkinsonians is strikingly peculiar. When the patient 
rises from the chair, he hesitates a moment as if to take aim, and starts 
ahead in a direct line, his laggard legs trotting to keep up with the for- 
ward-leaning body. In some instances the patient is strongly impelled 
forward, and can only arrest himself by running into objects or passers-by. 
There may or may not be an actual tendency to fall forward, or propul- 
sion, but in some cases, if the body be started backward, sideways, or 
forward by a push, the direction is maintained for a few or many steps, 



fa 4A -fAaACLrrf:.. 




Fig. 238. — Handwriting in Parkinson's disease, with former style below. 

giving rise to the terms lateropulsion and retropidsion, and these may 
occur spontaneously on getting up or in attempting to stop while ad- 
vancing. As described by Stewart, 2 in advanced cases the method of 
getting into bed is characteristic. The patient climbs on to the bed, 
stands up, and, bending down very slowly, grasps the rail at the foot- 
board. Holding firmly to the bedstead he slowly sits down and then 
falls or rolls backward into the recumbent posture. 

x Bruns, "Neurolog. Centralbl.," Nov. 1, 1904. 2 "Lancet," Nov. 12, 1898. 

37 



578 NEUEOSES. 

The trembling- in shaking palsy may appear after rigidity has de- 
veloped or at the same time. It usually commences in one hand and 
arm and then invades the lower extremity, subsequently appearing in 
the opposite arm and finally in the opposite leg. In some cases it is 
bilateral from the start, but commonly it is more marked on one side 
than on the other, and may be monoplegic or more often hemiplegic for 
several years, eventually showing a tendency to diplegic distribution. 
Often it is steadily preceded in its advance by the rigidity, or the rigid- 
ity may be generalized and of long standing before tremor appears in 
the hands. It affects the distal portion of the extremities most. In 
the hands, where it customarily first appears and is most developed, it 
causes a rhythmical, alternating flexion and extension of the fingers, 
mainly at the metacarpal joints. The tremor may be limited to the index 
and thumb, or affect the interossei most, causing rolling of the fingers 
upon their long axes. The patient appears to be constantly rolling some 
small object, as a pill or a pencil, between his fingers and the opposed 
thumb. Sometimes flexion and extension of the wrist are added, and 
very rarely we encounter movements of pronation and supination. As 
a rule, the arm and shoulders are unaffected. In the lower extremity the 
tremor predominates at the ankle, causing the foot to drum on the floor 
as if with clonus. The toes are less evidently involved by tremor, but 
many patients complain of flexor cramping of the toes as a very early 
condition. This usually comes on while walking, and may bring the 
patient to a momentary standstill. The muscles of the thigh often par- 
ticipate in the tremor. The muscles on the back of the neck, shoulders, 
and dorsum of the body are least affected. The abdominal muscles 
apparently escape. In the great majority of cases the head does not 
tremble, or only does so by movements communicated to it from a dis- 
tance. In very rare cases, ho\vever, there is a rhythmic nodding, shak- 
ing, or rotation of the head that may persist even when the patient is 
recumbent. The eyelids exceptionally are affected, while the lips and 
lower jaw not rarely show a tremor synchronous with that in the hands. 

The great peculiarity of this tremor is its usual occurrence while the 
patient is at rest, during repose, and while the parts are supported. In 
a minority of cases, however, and in other cases at an early period, the 
tremor is intentional — that is, analogous to the tremor of multiple sclerosis. 
The tremor ceases during sleep, and usually it subsides momentarily on 
voluntary motion. In early cases, and particularly in cases presenting 
marked antecedent rigidity, the tremor may only appear on voluntary 
and sustained motion, as in reaching to the back of the neck or into a 
distant pocket, and must be carefully sought. The tremor is a slow one, 
of from four to eight oscillations in a second. Usually the movements 
are more rapid if of limited extent, as when confined to the fingers, and 
grow slower as they involve larger muscles. When both upper or 
all four extremities are involved by the tremor, there is a practical 
synchronous uniformity of rhythm at all points. The character of the 
tremor shows distinctly in the handwriting. The letters are formed 
slowly and are of fair proportions, but all the lines are tremulous, both 
upstrokes and stems. The writing tends to become cramped and small. 



MOTOR NEUROSES. 579 

Sometimes a lens is required to detect the tremor thus graphically 
demonstrated. 

The palsy never reaches a complete degree, and the paresis may be 
extremely slight. While patients may bitterly complain of a feeling of 
weakness and stiffness, they often show a normal amount of strength, 
even when the rigidity and tremor are very well developed. In ad- 
vanced cases, however, there is customarily some weakness, and this 
may even be extreme. These patients, as a rule, are loath to make ex- 
ertion of any sort. 

Sensory Disturbances. — The general sensibility is practically ob- 
jectively intact, but Palmieri and Arnaud 1 insist that the parts affected 
by tremor show decided hypalgesia, most intense in the distal portions 
of the limbs and gradually shading off toward the trunk. Karplus, 2 
in a study of 103 cases, never found objectively disturbed sensation 
without tremor, and subjective sensory complaints were noted in but 
35 per cent. Parkinsonians frequently complain of subjective feelings 
of heat, more rarely of cold, and often of dull aches and indescribable 
discomfort in the affected limb. It is not rare for Parkinsonians to 
complain of considerable pain in the early stages of the disease similar 
to rheumatic pains in joints and muscles. The heat sensations may be 
accompanied by vasomotor disturbance, showing itself in elevated local 
temperature, in profuse sweats, and in flushing. Sometimes patients seek 
cool rooms and throw off heavy clothing and bed-covering, even in 
winter. In the majority of cases complaining of heat the surface tem- 
perature is actually increased. In some cases areas of brawny shin are 
encountered on the brow or body, a condition suggestive of myxedema 
and of scleroderma. Often there is great restlessness, apparently due 
to the discomfort arising from muscular rigidity. The hands may be 
frequently moved or the patient insists upon the limbs being rubbed 
and moved about every few minutes. Muscular atrophy only appears 
in advanced cases, but even then is not extreme. There are no electrical 
changes or sphincter weakness. As this is a disease of the involutional 
period of life, Ave may find all the disturbances of senility as coinci- 
dental accessories. 

The mental state is likely to be mistaken for one of dementia, but, 
as a rule, these patients enjoy all their mental powers. There is, how- 
ever, the same inertia in the mental processes that marks the muscular 
state. They shun exertion, are chary of their thoughts, talk little, 
appear indifferent, and often require the incentive of strange faces or 
extraordinary circumstances to arouse them to a show of mental activity. 
This, taken with their inexpressive faces, is easily misleading. 

Course. — The disease is essentially chronic and progressive. The 
onset, insidious, as a rule, may be abrupt, following some mental or 
physical storm. The duration is from ten to forty years. In the 
extremely protracted cases the patients become more and more helpless, 
fall into a senile dementia, and die from intercurrent disease, usually 
pneumonia. Varieties have been described, but they are usually limited 
and undeveloped cases. Thus, the monoplegic and hemiplegic forms, 

1 "Clinica Med. Ital.," No. 6. 2 " Jahrb. f. Psych, u. Neurol.," 1900. 



580 NEUROSES. 

the form without tremor, the form without rigidity, and the form show- 
ing extension are named. The 2 )ro 9 nos ^ s * s bad, but there may be 
remissions. 

Diagnosis. — In typical cases the diagnosis is made at a glance. In 
early and undeveloped cases Parkinson's disease may be mistaken for 
posthemiplegic trembling, but lacks the history of a stroke. Senile trem- 
bling usually first affects the head and does not present the facies and 
rigidities, but intermediate cases may be found and both may coexist. 
Multiple sclerosis has its increased reflexes and intention tremor, hysteria 
its stigmata. 

Treatment. — If seen early, the case should be treated as one of 
cerebral arteriosclerosis (see p. 207). In several instances this plan of 
treatment has seemed to retard the development of the disease. Symp- 
tomatic medication is practically useless. Opium, hyoscin, and cannabis 
indica, given freely, temporarily control the tremor, but at the expense 
of the general health and welfare if continuously employed. Many 
patients find hyoscin useful as an occasional help to meet some social or 
business requirement. Massage, electricity, and strychnin give a little 
help for the time being in some cases. Persistent exercises, — both passive 
and active, — Swedish joint-movements, and gentle muscle kneading, if 
intelligently carried out for a long period of time, certainly benefit these 
patients in the earlier stages. Especial attention must be given to build 
up the extensor muscle groups of the limbs and trunk in order to 
overcome the natural tendency to flexed positions, and full passive 
movements to the same end should be perseveringly employed. For 
the same reason exercises or electrical treatments tending to strengthen 
or actuate the flexor muscles are to be avoided. Mental and 
physical fatigue must be shunned. Charcot noticed that the vibra- 
tions experienced in carriage and car-riding mitigated the tremor, and 
treated many cases by means of a jolting or vibrating chair with 
temporary benefit. 



THOMSEN'S DISEASE (MYOTONIA). 

In 1876 Thomsen, himself subject to the disease, fully described a 
muscular condition later called myotonia congenita, family myotonia, etc. 
It is a disorder manifest in the voluntary muscles, which show a stiff- 
ness and rigidity upon attempted use after a period of repose, and certain 
peculiarities of mechanical and electrical irritability. It is a rare dis- 
ease, numbering not more than a hundred recorded cases. 

Etiology. — The salient etiological feature of the infirmity is heredity. 
Most of the known cases have been in family groups, sometimes ex- 
tending over several generations and through several collateral branches. 
Occasionally the disorder has passed over a generation and again 
appeared. With and without direct heredity the family history is 
commonly surcharged with neuroses and psychoses. Males are appar- 
ently the more commonly affected. Von Bechterew 1 suggests that a 
self-poisoning or auto-intoxication is active in this condition, and Jacoby 2 

1 " Neurol. Centralbl.," Feb., 1900. 2 " Jour. Xerv. and Ment. Dis.," July, 1898. 



MOTOR NEUROSES. 581 

looks upon the disease " as due to an embryonal developmental disorder 
of the nerve-cells, consisting in the more or less diminished resistance 
of the cells to the influence of toxic processes." The disease is also 
related to the myopathies, as shown by the muscular contours and the 
occasional appearance of atrophy. 1 Paessler, Pelz, Rossolimo, Batten 
and Gibb, 2 and others have recorded upward of thirty cases in which 
the atrophy was the predominant condition. These are commonly 
designated as cases of myotonia atrophica, and constitute a marked link 
between the myopathies and the myotonies. 

Morbid Anatomy. — Various observers, upon examination of excised 
fragments of the affected muscles, have recognized a hypertrophy of the 
protoplasm and nuclei and a deficiency of striation in the enlarged 
muscle-fibers, usually with slight but insignificant increase of interstitial 
tissue. This constitutes, according to Deleage, a persistence of embryonal 
conditions. Jacoby insists that this appearance is an artifact that is 
not found if the tissue removed during life is not allowed to contract. 
Babes and Marinesco have noted deformity or maldevelopment of the 
terminal motor-nerve plaques. Schiefferdecker asserts that there is a 
distinct disorder of the sarcoplasm and disease of the muscle fibrils. 
The hypertrophy appears to be secondary and the increase of nuclei is 
proportional to it. In the only autopsy yet recorded, Dejerine and 
Sottas 3 found no changes in medulla, cord, or peripheral nerves. It 
is as yet impossible to say whether we have to deal with a pure 
myopathy, a trophoneurosis, or a congenital defect in the trophic and 
motor apparatus of the cord. 

Symptoms. — The awkwardness caused by the fixity of the muscles 
upon attempted use is noticed in infancy, or may appear at any time up 
to the twentieth year, or perhaps even later. In typical cases, when 
the subject desires to execute some movement, a more or less marked 
and prolonged contraction fixes the muscles in question. This gradually 
subsides and the movement is accomplished. Repetitions of the spasms 
occur progressively with less force and duration for the particular action, 
and finally cease to appear, but any change in the character or even in 
the rhythm of the movements may reinstate the muscular fixation. 
Thus, in rising from a chair the legs and thighs are held rigidly. Once 
erect, the first step is impeded, the second less so, and finally steps are 
taken with natural ease, but a halt, a sharp turn, or even a change of 
speed may again set up the spasm. All the voluntary muscles may be 
affected, even to those of the thorax, eye, and tongue, but usually the 
myotonia is most marked in the lower extremities, and in some cases the 
face and upper extremities escape. The congenital paramyotonia of 
Eulenberg, in which symmetrical groups of muscles are affected mainly 
on direct exposure to cold, appears to be a limited form of Thomsen's 
disease. Both varieties have been observed in the same patient by Bern- 
hardt. 4 The sphincters and unstriped muscles escape, and in the case 
mentioned by Eulenberg the heart-muscle was normal. Gaping, sneez- 
ing, cold, wet, fatigue, and emotional excitement provoke the spasms, 

i Bernhardt, " Allg. med. Centralzeit," No. 14, 1890. 2 " Brain," 1909, p. 187. 
3 " Key. de Med.," Mar., 1893. 4 Loc. cit. 



582 NEUBOSES. 

while warmth, moderate exercise, repose, and quietude diminish their 
intensity. They are in some measure relative in intensity to the vigor 
of the attempted movement. 

Commonly, the affected muscles are of unusual firmness and increased 
bulk, but of lessened power, giving an appearance of athletic develop- 
ment at variance with the actual weakness, in many cases suggesting a 
pseudohypertrophy. They are perfectly supple to passive movements. 
The reflexes are normal, but a tap on the tendon is likely to produce a 
spasm in the anterior femoral group, modifying the usual response. 
Electrical and mechanical excitations of the motor nerve-trunks produce 
perfectly normal responses, or they are, if anything, somewhat dimin- 
ished. In the muscles it is very different. A slight blow, as with a 
percussion hammer, produces a persisting welt from localized muscular 
swelling or myoidema. The galvanic current produces sluggish, pro- 
longed contractures upon closure almost equally with either pole. Anodal 
or cathodal closing tetanus may often be secured with the continuous 
passage of five to ten milliamperes of current, and anodal opening tetanus 
is not infrequently observed. The strong faradic current produces undu- 
latory contractions in many muscles, and these sometimes attend the 
passage of the continuous current. Repeated electrical or mechanical 
stimulation of the muscles, like volitional use, gradually exhausts the 
myotonic responses. 

As varieties, Jacoby would limit the term congenital myotonia to 
cases (1) presenting a hereditary etiology either as a direct transfer 
from the ascendant, or by inherited disposition ; (2) manifesting the 
myotonic disorder of movement — namely, intention spasm ; (3) showing 
the myotonic reaction, which he describes as made up of normal 
mechanical and faradic excitability of the nerves and increased mechan- 
ical and faradic excitability of the muscles, anodal and cathodal con- 
tractions being equal and the response always being tonic and prolonged ; 
(4) persisting hypertrophy of the enlarged muscles ; and (5) absence 
of symptoms pointing to gross involvement of the nervous system. 
Other varieties of myotonia he would denominate myotonia aquisita, as 
describing those acquired subsequent to birth, and myotonia transitoria 
for the cases due to exposure to cold, etc. Lannois 1 has noted an 
association of progressive muscular atrophy and myotonia in an individual 
of apparently excessive muscular endowment and finds that about a 
dozen such cases have been reported. 

Psychic disorders are frequently associated, but not necessarily present. 
The malady, once developed, tends to persist for life, which it does not 
abridge. It is an incurable infirmity, but sometimes shows arrest or 
amelioration. 

Diagnosis. — The myoidema and myotonic electrical reactions, taken 
with the intention spasm, if the term may be used, make the diagnosis 
easy. Tetany has its distinctive signs in the phenomena of Trousseau and 
Chvostek. Pseudohypertrophic paralysis has peculiar deformities, con- 
tractures, and weakness without intention cramps. It subsequently 
shows atrophies and has no myotonic reactions. 

1 " Xouv. Icon, de la Salpet.," Nov., 1904. Also W. Furnrohr, " Deutsche Zeitsch. 
fur Nervenheilk., 1907. 



MOTOR NEUROSES. 533 

Treatment. — The causes which provoke the myotonic cramps, such 
as overexertion, fatigue, exposure to cold, and excitement of all sorts, 
must be avoided. Massage, reasonable exercise, electric baths, and 
cerebral galvanization have been recommended. 1 A careful search for 
toxic factors should be made, and conditions known to be attended by 
them should be corrected. 

FAMILY PERIODIC PARALYSIS. 

There is a form of periodic limp paraplegia that may be designated 
family periodic paralysis. It is characterized typically by recurring 
attacks of pure flaccid motor palsy, most pronounced in the lower ex- 
tremities, marked by diminished reflexes and lessened electrical and 
mechanical muscular excitability. The intervals are those of ordinary 
health, and there is a decided family and hereditary tendency. 

The first definite outline of this condition was given by Westphal, 
in 1885. Additional material has been contributed by Goldflam, Op- 
penheim, Bernhardt, Hirschl, and other German observers, and by 
Burr, Taylor, Mitchell, Putnam, and Crafts in this country. Oddo 
and Audibert 2 Avere able to collect 64 published cases. 

Etiology. — Heredity is most apparent. Taylor noted that thirty-five 
cases had been reported in three families, nineteen in one of them, and 
in two instances it had appeared in five consecutive generations, descend- 
ing through both sexes, which are about equally represented. Nearly 
all known cases presented attacks before the age of twenty-five, the great 
majority in youth, rarely, however, before the tenth year of life. The 
inciting causes of the attacks have been exertion, fatigue, and mental 
strains. Goldflam, in 1890, suggested that there was an autotoxic causa- 
tion acting upon an inherited vulnerability of motor nerve-cells, and 
Crafts 3 and Irwin have been able to isolate an extractive from the feces 
passed immediately after an attack which produced temporary paralysis 
when injected into rabbits and guinea-pigs. The amount of urea ex- 
creted during the attack also appears to be diminished. These results 
have not been confirmed. 4 Somewhat analogous attacks due to 
malarial infection have been cured by quinin. The muscular contours, 
and in Bernhardt^ case atrophy of the thenar eminences and continued 
muscular weakness, imply a relationship to the progressive muscular 
atrophies and to the myotonias. Examination of muscular fibers taken 
from the living subject also indicates a similar kindred. Bornstein 
suggests 5 that this disorder may be related to, if not identical with, 
epilepsy. His reported case was epileptic before the paralytic attacks 
appeared, and apparently substituted them, and there also was an epi- 
leptic sister. Schachnowicz 6 has reported an instance in which the 
patient's father was similarly affected, and his brother was an epileptic. 
After many years of periodical paralysis these attacks subsided and epi- 
leptic attacks occurred. 

Symptoms. — The attacks come on rather slowly within a few hours, 
usually at night, or during sleep. They are sometimes preceded by a feel- 

1 W. von Bechterew, " Neurolog. Centralbl.," Nov., 1897. 

2 "Arch. gen. de Med.," 1902. 3 "Am. Jour. Med. Sciences," June, 1900. 
4 Mitchell, Flexner, Edsall, "Brain," 1902. Singer, "Brain," 1901. 

6 " Deutsch. Zeitschr. f. Nervenheilk.," Nov., 1908. 6 " Wratsch," 1882. 



584 NEUROSES. 

ing of weariness, numbness, formication, sweating, heat, desire to urinate, 
headache, backache, rapid pulse, coldness of the legs, etc., in various cases, 
but all prodromata may be lacking. In some instances the attacks be- 
gin as a migraine or alternate with migraine. 1 The lower extremities 
are uniformly most affected, and the paralysis may be limited to them, 
but in other instances involves every skeletal muscle except those con- 
trolled by the cranial nerves, so that the patient is inert from the chin 
downward. A facial weakness has been observed in one case. Even 
the voice and respiratory efforts may be weak, sneezing and coughing 
impossible, and the heart has in certain instances been found dilated and 
with evidence of mitral insufficiency, both disappearing with the attack. 
Such attacks last from an hour to a week and tend to uniformity in a 
given case. The paralysis recedes in the reverse order of invasion. 
Attacks may recur daily, weekly, or once in several years. 

During the attack electrical responses in nerve and muscle and the 
tendon reflexes are lessened or completely abolished, but there is neither 
reaction of degeneration nor sphincteric incompetence. Mechanical 
stimulability of the muscles and nerves also usually disappears. Born- 
stein 2 reports a case in which the tendon reflexes persisted and at times 
were increased during the attacks, though the electrical excitability was 
diminished or even abolished. The mind and general sensation and the 
special senses are unimpaired. The attack subsides about as rapidly as 
it develops, and in the intervals the health is usually perfect. Indeed, 
many of these patients are described as unusually robust and commonly 
very muscular. The muscular contours at times have even suggested 
the myopathic family disorders. 

Diagnosis. — The diagnosis in familial cases should be easily made. 
In sporadic instances the behavior of the reflexes, electrical and me- 
chanical responses, periodic recurrence and absence of mental and 
sensory disturbances, should be sufficiently definite to distinguish the 
condition from hysteria, with which it has been confounded. A first 
attack may suggest Landry's paralysis, but again reliance may be placed 
on the quantitative electrical change. 

Prognosis and Treatment. — Thus far no treatment has been of 
much service, but those conditions, such as fatigue, which appear capable 
of inducing attacks in given instances must be avoided. In the mi- 
grainous cases bromid and caffein have proven useful. Holtzapple 3 
asserts that he has derived great benefit by the administration of bromid 
of potassium with caffein citrate both in aborting the attacks and 
curtailing those already established. The tendency is for the disease 
to endure for life without compromising it. A further knowledge of the 
toxic states may furnish the key both to the pathology and treatment of 
this rare disease. 

FAMILY TREMOR. 

A tremulous condition, particularly of the hands, but also in some 
instances involving the head, face, and tongue, closely resembling the 
tremors of multiple sclerosis, senility, alcohol, and mercury, is encoun- 

i Holtzappel, "Am. Med.," April 30, 1904. 

2 "Deutsch. Zeitschr. f. Nervenheilk.," Band 35, S. 407. 

s "Jour. A. M. A.," Oct. 21, 1905. 



FATIGUE NEUROSES. 585 

tered as a family trait. It may be traced through several or many gen- 
erations, and affects a large proportion of the family members, appearing 
before forty and usually before twenty years of age. 

The majority of such families are markedly neurotic, and, accord- 
ing to Raymond, the tremor may be considered as a stigma of 
degeneracy. In character the tremor is usually fine and rapid. It is 
accentuated by effort, fatigue, and emotion, ordinarily does not occur 
during rest, but generally closely resembles the intention tremor of 
multiple sclerosis. 



CHAPTER IV. 
FATIGUE NEUROSES. 

Many occupations requiring the constant repetition of certain pre- 
cise muscular movements may, eventually, through overuse and fatigue, 
give rise to disturbances of muscular control for the manoeuver in 
question. The condition may be manifest as pain, tremor, weakness, 
or cramp, but usually these are variously combined. This group of 
motor disturbances is also called occupation spasms or occupation neu- 
roses. Many of them are described under terms indicating their par- 
ticular avocational association, as scriveners' palsy, piano-players' 
cramp, seamstresses' spasm, etc. We may take writers' cramp, the 
most commonly encountered one, as a type, and then only an enumera- 
tion of the other forms will be needed. The more delicate and highly 
differentiated the functional movements, the more readily does their 
repeated overuse set up this inhibitory condition. Xo definite anatom- 
ical changes have been found, but it is probable that improved methods 
will demonstrate morphological alteration of the nuclear gray. Vig- 
ouroux 1 claims to have found changes in nerves and muscles in many 
cases, and supposes them to be present in all. 

WRITERS' CRAMP. 

Writers' cramp is variously known as scriveners' palsy, grapho- 
spasmus, mogigraphia, chirospasm, etc. 

Etiology. — A neuropathic heredity and a neurotic make-up are 
very common among sufferers from writers' cramp. The neurosis has 
exceptionally been noted in brothers and in parents and children, but, 
ordinarily, there is merely a transmitted nervous tare constituting a 
tendency to the development of the disorder under the provocation of 
overuse of a certain functional group of muscular movements. It is 
much more common in the male than in the female sex, perhaps owing 
to the greater proportion of men engaged with the pen. It most com- 
monly develops between twenty and fifty years of age, being very rare 
before and after these extremes. Its greatest incidence is between 
twenty-five and thirty-five. It is very likely to appear during periods 
of physical or mental strain, especially after protracted anxiety arising 

i "Progres Medicale," quoted in "Amer. Medico-Surg. Bulletin," Jan. 25, 1897. 



586 



NEUROSES. 



from any cause. Occasionally, some local injury to the hand or arm 
which entails additional difficulty in the mechanical process of writing 




Fig. 239.— Unstimulated cell from poste- Fig. 240.— Cell from posterior spinal gan- 

rior spinal ganglion of cat (from Hodge, after glion of cat. First effect of stimulation (from 
Tuke). Hodge, after Tuke) . 

may serve to provoke it. Neuritis, neuralgia, and hemiplegia affecting 
the writing arm have been followed by the neurosis. The principal 
inciting cause of the trouble is excessive writing in a bad manner — that is, 
in any style that depends upon the employment of the small muscles of 
the hand, wrist, or forearm in chief, and in which the writing move- 
ments are not made entirely from the shoulder. Thus, writers' cramp is 
practically unknown among stenographers, in spite of the rapidity and 
tediousness of their work, owing to the fact that the characters employed 
are best made by the freehand method customarily employed. Gowers, 
indeed, encountered a stenographer who could write shorthand readily, 
while ordinary script caused a spasm. 

Pathology. — Numerous theories have been advanced regarding the 
pathology, and the seat of the disease has been variously placed in the 
muscles, in the nerves, in the spinal centers, in the cerebellum, and in 
the cortex. We can, at once, rule out the muscle and the nerve as 
initial loci, if the muscular control for movements not of the particular 
occupational variety are fully, promptly, and normally executed. It is 
impossible to conceive of a peripheral lesion which would disturb only 
a certain purposive function, leaving others intact. On this point W. 
E. Paul 1 insists that a careful scrutiny will discover a certain amount 
of defect for all activities of the involved muscle groups. He attrib- 
utes etiological importance to the traumatic effect of repeated muscular 
contractions upon nerves, nerve-endings, and muscle tissues. A low- 
grade neuritis is undoubtedly present in some cases, and Vigouroux, 
already quoted, thinks it invariably present. In most all cases the 
motor function at fault is one to which the motor apparatus has become 
trained and habituated. In some degree it is automatic and subcon- 
scious. Such acts are generally supposed to be largely subcortical. 
Another factor is interposed by the fatigue element. Hodge has clearly 
demonstrated the changes in motor cells resulting from physiological 
fatigue. In the occupation neuroses it is at least supposable that the 

1 "Jour. A. M. A.," 1911. 



FATIGUE NEUROSES. 



587 



1 




Fig. 241.— Cell from posterior spinal gan- 
glion of cat. Later effect of stimulation (from 
Hodge, after Tuke). 



fatigue may overpass the limit of recuperation. "Well-authenticated 
cases in which muscular atrophy without sensory defects has succeeded 
the spasm would indicate rather conclusively that such was the case, 
that the motor cells of the cord were at fault, and that their trophic 
powers were finally involved. Sen- 
sory and motor symptoms, func- 
tionally grouped, would also point 
to the cord, but it is impossible as 
yet to exclude the superior cortical 
centers. In the neuritic cases ten- 
derness and sensory faults are of char- 
acteristic anatomical distribution. 

Symptoms. — The onset of writ- 
ers' cramp is commonly insidious. 
It is noticed after writing a con- 
siderable time that there is sensory 
discomfort or motor difficulty. The 
hand aches, feels numb or weak, or 
may become cramped or tremulous. 
After a moment's rest and a little 
rubbing writing may be resumed 
for a time, when the trouble reap- 
pears and gradually less and less work is required to induce the 
disabling condition, until in extreme cases merely putting the hand in 
the writing position may cause it. Several forms have been described 
depending upon the major symptom. Thus we have the spastic, tremulous, 
neuralgic, and paralytic varieties ; but they are very rarely pure, most 
cases showing a combination of sensory and motor features. Ordinarily, 
the cramp is painful not from the muscular contraction, but because the 
parts are affected with neuralgic pains that are occasioned only by the 
act of writing. In some instances they are so severe as to alone attract 
the patient's attention and inhibit the act of writing. In other and 
much rarer cases a feeling of weakness appears to prevent the use of 
the pen, but it is usually associated with pain. Tremor may be the 
principal feature, and is practically a manifestation of weakness. 

Motor Disorders. — In the case, Fig. 243, illustrated from photo- 
graphs, the plan of holding the pen between the index and middle fingers 
was adopted when spasm first developed, and for a time permitted a 
continuation of clerical work. "When seen later, the hand would begin to 
cramp after half a dozen words were written, as shown in the second 
cut, and in a moment the spasm would become violent, the pen would 
fall, and the fingers and thumb would be extended as shown in the third 
cut. This was an aggravated case. Commonly, as soon as the spasm 
causes uncertainty in writing the act is stopped and the spasm subsides. 
It may cause a great change in the writing, which tends to become 
cramped and full of uncertainties and zigzags. The pen is forcibly 
jerked and thrust in various directions. At first, by steadying the 
writing hand with the other, and adopting a thick penholder or one 
fitted with a ball held in the palm of the hand or with rings against 
which the fingers are pressed in extension, writing may be continued for 



588 



XECJROSES. 





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Ce^je^oe^ 




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< 
3 








^c5<.--*-^/r ■ * 


< «• 


,/z 





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Fig. 242.— 1, Writers' cramp, handwriting in 1894: 2, copy of same made very slowly in 1897 by 
patient; 3, written by aid of left hand, same patient, 1897 ; 4, same patient", 1897. 



FATIGUE NEUROSES. 



589 



a time, but usually the spasm reappears. If the other hand be then 
used, it is not uncommon for the spasm to appear on that side after a 
few months, though this is not invariably the case. AYhen the spasm 
affects the second hand, it may also cause the muscles of the first hand to 




Fig. 243. — Writers' cramp (from photographs) : 1, Pen held between fingers at first gave relief; 
2, spasm beginning in thumb and index ; 3, fully developed spasm, throwing all the digits except small- 
est finger into extension and causing the pen to fall. 



contract. The spasm may also spread to the muscles of the forearm 
and even to the arm and shoulder. 

In cases of moderate severity the spasm may be occasioned only by 
the act of writing, but sometimes, and in severe cases usually, other 
acts requiring precision in finger movements also call it forth. In 
telegraphers' cramp, writing with the Morse key or the pen often alike 
causes the spasm ; musicians may experience the spasm both in instru- 
mental manipulations and in writing ; seamstresses by using the needle 
or the scissors, etc. 

The power of the hand for coarse muscular efforts may be unim- 
paired, but in cases of long standing some weakness in the muscles most 
concerned is commonly found, and in such cases slight wasting may 
occur. In rare instances, when the use of the affected member is 
pushed in spite of the disability, permanent atrophy may result. In 
figure 244 is shown the hand of a seamstress in which local pain and 
spasm were finally followed by atrophy, the reaction of degeneration, 
and fibrillary twitching limited mainly to the radial half of the hand and 
ulnar border of the forearm, namely, to the muscles chiefly concerned in 
the use of needles and scissors. The electrical responses in muscles and 
nerves may be normal, but in protracted cases there is usually an 
increase and finally a decrease of excitability, and, as in the rare case 
illustrated below, the reaction of degeneration may be present. 

Sensory Disorders. — The sensory disturbance is sometimes de- 
scribed as one of great fatigue, or there may be pain and tenderness. 
Tenderness along the course of the nerves is not uncommon. In some 
cases pain is located in the small bones and joints of the wrist or 
fingers. It may only occur on attempts to write, and it may or may 
not be preceded by spasm. In certain cases it extends to the arm, 
axilla, and shoulder. Such paresthesias as " pins and needles," ting- 
ling, ache, " tired feeling," etc., are often complained of, and may 
similarly extend up the arm. Actual hyperesthesia or anesthesia are 
encountered only when neuritis is associated. 

Course. — Commonly insidious in onset, writers' cramp may develop 



590 NJEUEOSES. 

with some suddenness, after an emotional, moral, or physical storm, and 
tends to progress so long as writing is persistently attempted. If the 
opposite hand be trained, it usually also becomes the seat of cramp, which 
is likely to increase more rapidly than on the side first affected. If 
writing be completely abjured, the cramp gradually becomes less and 





Fig. 244.— Wasting of muscles in a severe case of seamstress' cramp. 

less, and may entirely cease after a few months or a year, but is very 
likely to return if continuous writing is again taken up. The tendency 
of the cramp, pains, and paresthetic sensations to persist and increase 
if the writing occupation is continued is pronounced, and there is 
danger of pushing the condition into one of organic changes, with 
atrophy and permanent palsies. 

Diagnosis. — The diagnosis is usually made by the patient, and 
nearly every large clerical force or telegraph office furnishes cases. 
Monoplegia and hemiplegia from organic brain disease are some- 
times mistaken, as the patient's attention is first attracted by his clum- 
siness in writing. Musculospiral palsy, neuralgias, and rheumatic pains 
are occasionally mistaken for writers' cramp, but in all these condi- 
tions the symptoms are persistent and not alone provoked by writing. 
Spasm, usually present in writers' cramp from the first, is also absent. 
Hysteria may present limited tremor and motor difficulty, but the dis- 
ability is not confined to writing, and sensory stigmata are added. 

Prognosis. — The prognosis is very unfavorable if writing be per- 
sisted in. If the patient can completely abstain from the use of the pen 
or similar writing implements, the spasm tends to subside and disappear 
unless the case is of long standing and so aggravated that all sorts of 
finger use induce the cramp. The neuralgic cases are somewhat more 
easily managed than the cramp variety if prolonged rest can be secured. 
The presence of any removable diathetic disability, as lithemia, favorably 
modifies the outlook, and the termination of general depression, physical 
or mental, may lead to marked improvement in the spasmodic affection. 
The tendency to recurrence and to extension has already been noted. It 
is rare for a patient, even after years of rest, to be able to return to 
writing occupations without a reappearance of the neurosis. 

Treatment. — Recognizing the fatigue element in the production- of 
writers' cramp, rest becomes the principal note of treatment. All 
physical failings and conditions which tend to make fatigue of ready 
appearance must be scrupulously sought and carefully managed. Abso- 



FATIGUE NEUROSES. 591 

lute cessation of writing is of the first importance. Unfortunately, 
patients whose living depends upon clerical work will not or cannot 
conform to these requirements until the neurosis completely disables 
them. Exercises to develop the strength of the arms, hands, and 
fingers should be employed, and massage, baths, and electricity, for their 
general tonic effect, are of some service. Gordon claims to have se- 
cured immediate and lasting improvement by the local application of 





Fig. 245.— 1, Splint to immobilize hand and wrist in the treatment of writers' cramp ; 2, splint in use. 

Bier's method. When writing is again taken up, it must be by the 
proper full-arm movement. A typewriting machine can often be sub- 
stituted for the pen. The use of spinal sedatives to control the cramp 
and permit a continuance of writing is pernicious, and rarely gives even 
temporary help. When writing is resumed, the free-hand method from 
the shoulder must be employed, and the splint (Fig. 245) affords a help 
by immobilizing the wrist and fingers during writing exercises. 



OTHER OCCUPATION NEUROSES. 

The general considerations pertaining to writers' cramp are equally 
applicable to the other occupation neuroses, and with proper modi- 
fication the particular features are identical. Among the occupa- 
tion spasms more commonly encountered are the cramps of violin and 
pianoforte players, telegraphers' cramp, seamstress' cramp, and 
hammer cramp in smiths and artisans using the hammer. Artists, 
flower-makers, turners, watchmakers, knitters, engravers, masons in 
using the trowel, sailors from pulling on ropes, treadlers, compositors, 
enamelers, cigarette-makers, shoemakers, milkers, money-counters, 
letter-sorters, and players on various musical instruments, including 
drummers, comprise the list given by Gowers. It has been noted in a 
shoe salesman from the stooping position needed in putting on shoes, in 
gum-chewers, affecting the masticatory muscles, and in various factory 
employees who incessantly use the same movement in feeding or at- 
tending some machine. Clergymen and other public speakers, from a 
faulty use of the vocal apparatus, may acquire a laryngeal neurosis that 
is manifest every time the voice is strained, causing a sudden loss of 
modulation, which may end in continuous vocal disability. A spasm of 
a similar nature, involving the lumbar muscles, has been seen in physi- 
cians, due to continuous riding in carts or buggies. 



592 NEUROSES. 

CHAPTER V. 
NEURASTHENIA. 

In 1869 Beard, of New York, directed general attention to a 
nervous state or condition marked by irritable weakness, and adopted 
for it the name of neurasthenia. It is familiarly known as nervous 
prostration or nervous exhaustion, and is a fatigue neurosis. In Europe 
it was at first somewhat derisively called the American disease or Beard 7 s 
disease. It is now recognized the world over as a morbid state ; as one 
of all time, and not a product of modern life or of American condi- 
tions. It is marked by a host of subjective symptoms and a very few 
objective phenomena, all more or less variable, and most of them incon- 
stant. As a rule, all forms of nervous energy — psychic, motor, and 
organic — are reduced, so that fatigue is more quickly occasioned than in 
health. There is less endurance, and consequently greater irritability, 
which most shows itself in the mental sphere. The whole state is 
summed up in the classical term " irritable weakness/' 

Etiology. — Neurasthenia seldom occurs before twenty years of age 
or after fifty. It is essentially a disorder of the energetic, productive, 
troubled period of life. Both sexes suffer, and perhaps in equal 
proportion, but in females a more common association with hysteria 
frequently carries these cases into that list. Cleghorn, 1 basing his con- 
clusions on statistics embracing 6000 cases, finds neurasthenia much more 
frequent in men than in women, and two-thirds develop between the ages of 
twenty and forty. Indoor occupations bulk heavily in the list. In this 
country the high altitudes of the western plateaus and the extremes of 
climatic conditions in the northern, and particularly the northwestern, 
States apparently account for the greater frequency of neurasthenia in 
these localities than on the seaboard and in the southern States. The 
persistent winds of the prairie States seem also to be active in the causation 
of neurasthenia. All races present the disorder. Hebrews and Slavs are 
said to be very subject to it, and Scandinavians, at least in this country, fur- 
nish a large contingent. A neuropathic heredity is less common than in 
hysteria or epilepsy, but neurasthenics are very commonly found at the 
head of a neuropathic strain. Debilitating conditions in the antecedents of 
neurasthenics are very common. Gout, rheumatism, tuberculosis, sy- 
philis, excesses, dissipation, malaria, and all the cachexias in parents are 
likely to discount the stamina of offspring and favor the early limitation of 
endurance and vigor demonstrated in neurasthenia. A defective educa- 
tion that omits discipline and the cultivation of self-control, poorly fitting 
the child for the rude shocks of later life, may be a predisposing cause. 
Educational methods that overtrain and overstrain may directly induce 
the neurosis. Occupations of all varieties furnish neurasthenics. It is 
only requisite that the element of overwork come in, whether the labor be 
mental or physical. Overwork, moreover, is a variable quantity, relative 
to the forces and endowments of the individual. 

1 "Med. Rec," April 27, 1907. 



NEURASTHENIA. 593 

Among the inciting causes overwork is the most common, and asso- 
ciated with it we usually encounter anxiety, worry, or excitement, which 
depress the patient's forces, often at the same time impelling him to 
greater efforts. The business man, anxious for his ventures, works 
doubly hard to secure success. The sleepless mother, worn with care 
and nursing, does double and treble duty, and finally "goes to pieces'' 
when the strain is over. The overtrained athlete goes " stale." 
Excesses, by their debilitating effects, are frequent sources of neurasthenia. 
Alcohol, tobacco, venery, masturbation, either as onanism or withdrawal, 
unnatural stimulation of sexual responses, and, very rarely, sexual con- 
tinence may result in the general depression we call neurasthenia. 
Trauma, both physical and mental, may induce neurasthenia, and is 
likely to do so in proportion as the psychic shock is well developed. 
Railway accidents may breed neurasthenia in those who do not receive 
a scratch. The fright is often worse than the blow. Together they 
may cause a double injury. A muscular strain from overexertion, as 
in lifting, may start neurasthenia, particularly if the back be hurt and 
there is suggestion or fear of serious harm having been done. The more 
neurasthenia is studied, the more prominent will its mental side become. 
Exhausting illness, either from acute or chronic disease, may cause 
neurasthenia. Various toxic states, such as lithemia and syphilis, are 
prone to produce it. It is usually difficult, and often impossible, to 
determine the exact cause of neurasthenia in a given case. Ordinarily, 
there are a number of both predisposing and exciting causes. In a 
large number of instances neurasthenia is secondary to and symptomatic 
of organic conditions, such as phthisis, Bright's disease, diabetes, gout, 
rheumatism, uremic and toxic states generally. 

Pathology. — Although we know no pathological anatomy of the 
disorder, its manifestations are those best explained by a diminished 
dynamic energy and lessened recuperative power in the cerebrospinal 
axis, and especially in its cellular elements. This may be a nutritional 
defect. The very constant factor of persistent overwork, overstrain, 
and overfatigue in the causation of neurasthenia, coupled with Hodge's 
findings in the motor cells after an expenditure of energy, leads to 
the opinion that we have to do with a fatigue neurosis, general in 
distribution and comparatively slight in degree. With this view in 
mind, we will be the better able to understand the symptomatology and 
the requirements for treatment. 

Symptoms. — The symptoms of neurasthenia are extremely numer- 
ous. Some of these are essential, most are adventitious. Charcot con- 
sidered headache, backache, gastro-intestinal atony, neuromuscular weak- 
ness, cerebral depression, mental irritability, and insomnia as the funda- 
mental symptoms of the disorder, — the true stigmata of the neurosis. 
Secondarily and inconstantly arise a host of complaints that are of less 
importance and significance. It will be necessary to take up the symp- 
toms seriatim. It may be said of them all that they indicate a deficiency 
of function, never an absolute want of it. The reduction is one of 
quantity rather than of quality, but is never absolute in degree. 

Motor Disorders. — A constant condition in neurasthenia is muscular 

38 



594 NEUROSES. 

weakness. The patients complain that muscular efforts are promptly 
fatiguing. They can only walk a few squares, standing a long time is 
exhausting, and exercise or use of the back and upper extremities pros- 
trates them. They often show a remarkable diminution of strength as 
registered on the hand-dynamometer or in lifting, but occasionally a 
patient can put forth one or two fairly forcible efforts, and then the 
strength quickly subsides. Sustained effort is impossible. As another 
manifestation of the generalized myasthenia, tremor is frequently observed, 
and can usually be provoked by comparatively slight muscular efforts. 
Lamarcq 1 found it in eighty-five per cent, of neurasthenics. Many 
patients complain of their trembling knees and shaking hands, or the 
tremor may appear in the handwriting, especially toward the end of a 
long letter, where the firmness of the strokes is also likely to be reduced. 
Tremor in the eyelids, lips, and face is sometimes noticed. Muscular 
twitchings in the face and extremities are not rare. The tendon reflexes, 
ordinarily, are increased. This is customarily the case with the knee- 
jerk. A tendency to widely distributed responses is frequently present, 
so that a tap on the patellar tendon causes starting of both lower limbs 
or of all four extremities, and sometimes gives rise to a complaint of 
pain in the back. If the knee-jerk be repeatedly produced, the inten- 
sified response first elicited may gradually subside, giving another 
evidence of the early fatigue of the nervous apparatus. In some in- 
stances a tap on muscle or nerve-trunk will call forth a similar response. 
Ankle-clonus is sometimes present, but is spurious in character, and 
only a few vibrations of the foot can be elicited. Repetitions of the 
test may fail to produce it. Paralysis or abolished knee-jerks are not 
found in neurasthenia unless due to other coincidental disease. 

Sensory Disturbances. — Neurasthenia never causes anesthesia. 
When this is present we have a condition of actual deficit, to which limit 
neurasthenia does not go. The vague subjective disturbances of sensa- 
tion, on the other hand, are limitless. Among them a feeling of general 
tiredness and fatigue is almost constant, and the recumbent posture 
tends to become habitual. 

Headache is one of the most common symptoms ; it is practically 
never wanting and often is described in striking terms. In some 
instances it is slight and constant, more often it is produced by any 
muscular or mental effort, and occasioned by any disturbing emotion. 
Usually it is occipital, " at the base of the brain/' as these patients are 
fond of saying; but it may be frontal, temporal, or vertical. One 
describes a sensation as if the head were splitting or the skull lifting ; 
another has a terrible weight or a severe constriction about the 
head. This lead-cap headache is very common. Heaviness, throbbing, 
buzzing, a sensation of wind blowing or of water running under the scalp, 
and many others are perhaps indicative of the vasomotor disturbances 
within the skull. Almost never is the headache a veritable pain, but 
rather some variety of discomfort difficult to describe. Backache is 
equally common with headache. It is probably a fatigue symptom for 
the most part, though sometimes referable to gastro-intestinal dis- 
1 "Revue Neurol.," August 15, 1897. 



NEURASTHENIA. 595 

turbances. The small of the back is its usual seat, whence it streaks 
up between the shoulders or through the loins and down the limbs. 
Very commonly it is associated with a "drawing" sensation at the back 
of the neck, and the occipital pain is then usually complained of. By 
lying down or by padding a chair with pillows, some relief is obtained. 
The advanced case customarily assumes one of these expedients. In 
milder cases the backache is occasioned by any effort or disturbing 
circumstances and subsides upon rest. 

Tenderness is usually found over the spine and is rather superficial 
in character, but occasionally is intensified by deep pressure. Rarely 
the spine is tender its entire length ; usually only small sensitive spots 
are present. The upper cervical spine near the occiput, over the 
vertebra prominens, opposite the lower angle of the scapula, at the waist- 
line, at the top of the sacrum, and over the coccyx are the favorite 
locations. Sometimes the tenderness is diffuse and the skin over the 
entire dorsum is painfully over-sensitive. Sometimes this sensitiveness 
prevents the dorsal decubitus or interferes with sitting up. It is likely 
to be aggravated by anything which disturbs the patient or increases 
the other symptoms. Sensitiveness on the head, limbs, or other por- 
tions of the trunk is not rare, and is usually associated with spontaneous 
pain in the same location. The outlines of these sensitive areas are 
never sharply defined, and they may shift position or vary in intensity 
within a few hours or days, but sometimes remain practically stationary 
for months. 

All manner of vague sensations of heat, cold, prickling, tightness, 
numbness, stiffness, weakness, fatigue, soreness, pain, pressure, etc., 
referred to this or that part of the body or limbs are constantly encoun- 
tered. In addition there are a host of abnormal feelings referred to the 
thoracic, abdominal, pelvic, and generative organs. 

Visual Disturbances. — The neurasthenic commonly complains that 
reading has grown difficult because it causes headache and vague 
distress, and states that the letters blur or run together after a few 
minutes. In other instances they can not maintain attention. Careful 
examination will usually demonstrate that the accommodative apparatus 
and the retinal sensitiveness are promptly fatigued. One is a motor loss, the 
other a sensory deficiency. The first is shown by the rapidly diminish- 
ing ability to clearly make out the test-type ; the second, by the quickly 
narrowing visual field, due to impaired sensitiveness in the retinal 
periphery. Both may be regained after a slight rest. A high and 
oscillating degree of muscular asthenopia is usually due to neurasthenia, 
and commonly subsides as the nervous state improves. Deficiency of 
the interni is the usual finding. 

Photophobia may be encountered of sufficient intensity to keep 
patients in dark rooms or wearing colored glasses. In lessened degree 
retinal hyperesthesia is not uncommon, and is similar to the cutaneous 
sensitiveness. Misty obscurities and a veiling of vision are sometimes 
described, or everything looks strange and unreal. The pupils are 
usually very mobile, contracting and expanding excessively, sometimes 
sluggishly, sometimes very actively and even independently of light or 
accommodative efforts. Inequalities, both transient and persistent for 



596 NEUROSES. 

days, are rarely encountered. Permanent inequality is due to organic 
disease. 

Disorders of Hearing-, Smell, and Taste. — Hearing is apparently 
frequently disordered. Thus, patients start at the slightest sound, and 
often tie up the door-bell and seek seclusion to avoid all such irritation. 
This is as much mental as aural, perhaps, but tinnitus in various forms 
and throbbings in the ears are due to the irritable weakness that spares 
no nerve. Complaints of peculiar or bad smells and tastes have a 
similar significance. 

Gastro-intestinal Disorders. — Nervous indigestion is one of the 
commonest features of neurasthenia. The appetite is often capricious, 
and may be excessive or greatly diminished. The mere thought of 
food may be repugnant. In milder cases there are complaints of the 
food lying heavy or of gaseous eructations, which may or may not be 
attended by heart-burn. The gaseous gastric distention may suggest 
dilatation, and often provokes cardiac palpitation and precordial and 
epigastric distress. In more aggravated cases dilatation actually occurs, 
and hydrochloric acid may disappear from the gastric secretion. Di- 
gestion is retarded and deficient, but the tongue may remain clean and 
nutrition still be inadequate to maintain the body- weight. The small in- 
testine is usually affected in the same atonic fashion, causing constipation. 
In the severe cases of neurasthenia all these conditions are aggravated. 
The eructations of gas become frequent, noisy, and distressing ; meteor- 
ismus, colicky pains, alternating constipation and mucous diarrhea, intes- 
tinal fermentation, and the passage of undigested food mark the atonic 
and irritable state of the gastro-intestinal tract. Cases present great 
variations, and the same case is rarely consistent in regard to these 
features. 

Circulatory Disorders. — Cardiac 'palpitation due to digestive dis- 
turbance is one of the common symptoms in neurasthenia, but may 
result from other causes, as muscular or mental efforts, sudden starts or 
embarrassments of any sort. In some instances it reaches a high degree 
and is attended by precordial pain, a tumultuous heart's action, throb- 
bing arteries, and generalized distress. In other cases it may occasion 
a pseudo-angina pectoris that mimics a stenocardial attack very closely. 
A small, rapid pulse of about 90 a minute is commonly present in neu- 
rasthenia, and in attacks of palpitation it may reach 140 or 160. The 
rate is promptly increased in all cases by any distressing, exacting, or 
disturbing cause. Hemic murmurs are not rare in advanced cases, 
when the general nutrition has been reduced. The feebleness of the cir- 
culation is shown by the cold extremities commonly encountered. Vaso- 
motor storms in neurasthenia are the rule. Localized or general flush- 
ings, sweats, and aortic throbbing may greatly annoy the patients. 

Secretory Disorders. — The urine is ordinarily scant and high- 
colored. Neurasthenics drink little water, and the irritating urine may 
cause much vesical uneasiness and frequent micturition. There is com- 
monly an increase of uric acid and urates, or a great abundance of 
phosphates and oxalates may be noted, and the urine may be neutral or 
alkaline in reaction. All fluid secretions, as the perspiration, saliva, 
gastric, intestinal, and synovial fluids may be deficient. In other in- 



NEURASTHENIA. 597 

stances they are increased, or increase and deficiency may alternate. 
Some patients complain that the slightest effort or embarrassment causes 
them to sweat profusely, usually about the head and neck. The cold, 
clammy hand of neurasthenia is rarely wanting. 

Genital Disorders. — The average male neurasthenic complains of 
lessened sexual power. If unmarried, nocturnal emissions frighten him, 
and he is convinced that he has spermatorrhea by the cloudiness of his 
urine. If, perchance, there has been an antecedent habit of masturba- 
tion, every symptom is warped by him into relation with the supposed 
impotence, and he develops into a confirmed sexual neurasthenic with- 
out erections and with vague paresthetic sensations or actual tenderness 
and pains in the genitals that claim his undivided, brooding attention. 
If married, premature ejaculations and loss of sexual appetite in milder 
cases are followed by actual inability in the severer forms, and some 
sensory hyperesthesia or lessened sensitiveness of the parts may be found. 

In women analogous symptoms are encountered, but much less 
frequently. Some are troubled by nocturnal orgasms accompanying 
dreams from which they awake nervous, depressed, and exhausted. In 
married women sexual appetite may at first be somewhat increased, but 
quickly diminishes and commonly disappears, not seldom being followed 
by an actual distaste or even disgust. Pelvic pains and genital insen- 
sitiveness, or hyperesthesia, are often added, and further serve to inhibit 
intercourse. 

Mental Disturbances. — The psychic side of neurasthenia is an 
interesting and important feature of the neurosis. All the mental mani- 
festations of the neurasthenic have in common the same elements which 
dominate the physical features — namely, weakness and irritability. The 
capacity for mental work is abridged, just as the muscular power is 
reduced. Protracted mental efforts become irksome or impossible, and 
in many instances attempts to read or think or converse for a few 
minutes produce so much fatigue and discomfort 'that they must be 
discontinued. This mental asthenia also shows itself in the reduction of 
the mental concentration necessary for fixing and maintaining attention. 
Neurasthenics can not keep their minds on the printed page nor follow 
a line of thought for any great length of time. They are inattentive to 
details, and consequently do not clearly apperceive them. Hence arises 
the almost constant complaint of a loss of memory. Active spontaneous 
mentation, which is dependent upon mental strength, is also reduced. 
Ideas do not occur to such patients with their usual vigor and rapidity, 
and they often assert that they can not think. Their courage naturally 
subsides with their strength. Attracted by the cardiac palpitation or 
their sexual incapacity or their mental debility, or by any other neuras- 
thenic index, they become introspective, and, misconstruing their symp- 
toms, develop a lot of nosophobias. As the suggestions and reminders 
of these fears are constantly present, the neurasthenic becomes saturated 
with them, thus still further reducing the power of attention and mem- 
ory. They become morbidly self-watchful and tend to hypochondriacal 
depression. In some instances these morbid fears pass into insane delu- 
sions and obsessions, and are then beyond the boundaries of neuras- 



598 NEUROSES. 

thenia, but the dividing line is decidedly indefinite. Indeed, many 
psychoses begin as a neurasthenia and even general paresis may show a 
neurasthenic prodromal period. 

Fear, arising easily from a consciousness of weakness and a loss of 
courage, often becomes associated with external conditions and sugges- 
tions. An attack of palpitation in a crowded place may induce a 
condition of fear or apprehension constantly associated with like con- 
ditions. Some fear to be alone, others to be in open or in narrow 
or in high places. Some fear darkness, some storms, some lightning, 
some special localities, some contamination by dirt or infection by 
disease. The neurasthenic always recognizes the baselessness of such 
fears, though he may not be able to dispel them ; the insane hypo- 
chondriac accepts them as actual necessary facts, and can not be per- 
suaded to the contrary. When in neurasthenia the phobias become 
dominant, so that the patient is controlled by them, though recognizing 
their fictitious character, the condition constitutes an actual psychasthenics 
in the sense employed in the next chapter. 

Frequently the neurasthenic recognizes a diminished affection for his 
family or others, and sometimes is greatly troubled by it. He is 
irritable, peevish, fault-finding, and resentful. The business man dreads 
his daily tasks and dislikes to meet new customers or even old friends. 
The emotions are less stable, and there is ever a tendency to weakness and 
depression. Such patients are lacrymose on slight occasion or break 
down in telling of themselves or in contemplating their darkened future. 

Sleep is commonly faulty from the first. Neurasthenics habitually 
present insomnia. In some instances there is a difficulty in getting to 
sleep or the sleep is constantly disturbed. Exceptionally the sleep is 
sound and prolonged, but the patient aivakes unrefreshed, and usually 
more depressed and prostrate than upon retiring. Ordinarily, the sleep 
is disturbed by troubled dreams, which often are of a dreadful or night- 
marish character. a In shock or traumatic cases the accident episode 
may be repeated in the dreams night after night or several times the 
same night. Charcot laid especial stress upon such formulated dreaming 
in neurasthenia. 

The General State. — In neurasthenia of long standing the general 
nutrition is commonly defective, and high degrees of anemia and ema- 
ciation may be encountered. Neurasthenia of a moderate grade of 
severity, but sufficient to disable the patient for ordinary pursuits, is 
consistent with fair nutrition, and some of the most inveterate cases 
may become quite fat. Emaciation, on the one hand, is not a hopeless 
indication, nor, on the other hand, does plumpness indicate an easily 
manageable case. 

Forms. — In view of the multiplicity of symptoms in neurasthenia 
and their lack of uniformity in various patients, it is not surprising that 
numerous forms have been described. The terms cerebral, spinal, and 
sexual neurasthenia have been used to designate cases in which symp- 
toms referable respectively to the head, back, and genitals have pre- 
ponderated, but it is best to look upon neurasthenia as one and indivisible. 
Adventitious or exaggerated symptoms may variously tone the clinical 
picture in different cases, but neurasthenia remains a generalized disorder 



NEURASTHENIA. 599 

of the entire nerve-apparatus. In the foregoing description of neuras- 
thenia the simple variety has been constantly in view. We are always 
to have in mind that neurasthenia may be symptomatic of some organic 
process of which it is a secondary expression. Thus, it may follow 
all forms of extraordinary illness or injury, spring from the various 
cachexias, and succeed all toxic and infectious processes. All such condi- 
tions must be eliminated before we may call a case one of simple or essen- 
tial neurasthenia. Again, neurasthenia is frequently encountered in asso- 
ciation with other neuroses. This is particularly true of hysteria, and 
it is sometimes impossible to say where the neurasthenia ceases and the 
hysteria begins. For such cases the term hysteroneurasthenia has been 
employed. Psychasthenia is frequently associated with neurasthenia. 

Course. — Neurasthenia is essentially a chronic malady. Ordinarily, 
its onset is insidious, and it is only after weeks and months of growing 
incompetency and laborious efforts to carry on the usual duties that the 
patient recognizes something wrong and seeks medical advice. In the 
traumatic form of neurasthenia the neurosis may be quickly established, 
but it is not uncommon for the patient to go about as usual for several 
days or weeks after the accident or injury, and gradually develop the 
nervousness, weakness, and prostration. Once established, neurasthenia 
tends to persist indefinitely, and only some radical change in the mode 
of life, serving to relieve the patient of worry and work, is likely to favor- 
ably modify the condition. Frequently remissions are presented, but 
the patient relapses under any unusual demands, and slowly or partially 
regains the former status. Even after long periods of improvement 
there is a tendency to ready recurrence under the influence of any excit- 

; cause. 

Diagnosis. — The diagnosis of neurasthenia is usually easy. The 
combination of mental and physical weakness and irritability with 
gastro-intestinal atony, backache, headache, insomnia, and rapidly ex- 
hausted retinal sensitiveness, justifies the diagnosis. The difficulty mainly 
lies in overlooking some basic organic disease. One should never be 
content with a diagnosis of neurasthenia until he can thoroughly satisfy 
himself that he is not confronting a symptomatic form of the neurosis. 
Hysteria may be associated with neurasthenia, but has its own stigmata. 
It is to be kept in mind that disturbances of function in neurasthenia 
are those of irritable weakness and not of actual loss. Anesthesias, pal- 
sies, convulsions, complete loss of self-control, actual amnesias, are not 
the property of neurasthenia, but are the ear-marks of hysteria, True 
hypochondriasis is a variety of melancholia with actual insane delusions 
regarding bodily states. In neurasthenia the phobias are under at least 
partial control, and sometimes can be completely relieved by a reasonable 
statement of the facts. As before stated, all the changes of function in 
neurasthenia are in the nature of quantitative reduction. 

Prognosis. — The outlook in neurasthenia is commonly good if the 
proper treatment can be instituted and maintained. It is often very diffi- 
cult to secure the cooperation of the patient, or his circumstances may 
be such as to preclude the protracted rest and change usually required 
to restore him. In that event he worries along as best he can, possibly 
picking up some drug or stimulant habit, and may recover after many 



600 NEUEOSES. 

months, but is more likely to break down completely and become a 
confirmed nervous invalid. If of a psychopathic stock, some pronounced 
mental change may appear. Cases occurring before twenty years of age 
are likely to yield readily and to relapse frequently. Such early demon- 
stration of insufficient stamina naturally indicates an unstable organi- 
zation. After forty the prognosis is also less hopeful, as the neuras- 
thenic exhaustion occurs in tissues that have largely lost their resiliency 
and recuperative powders. After this age full vigor is practically never 
regained if the neurasthenic state has been severe. A neuropathic or 
psychopathic heredity or evidence of degeneracy in the patient reduces 
the chances for a full and permanent recovery. The bodily condition is 
of less significance if organic disease is absent. Cases of extreme emacia- 
tion often respond admirably to treatment, wmile some of the cases 
without marked disturbance of bodily function are inveterate. 

Treatment. — The keynote of treatment in neurasthenia is rest. 
Depending upon the severity of the case, upon the temperamental char- 
acteristics of the patient, and upon the sex, this rest may be partial or 
as complete as we can possibly make it. In the milder cases, especially 
those occurring from overwork in sedentary pursuits, in patients between 
the ages of twenty and forty, and when the patient's make-up is based 
upon a good heredity, the full Wier Mitchell rest treatment is commonly 
not required. It may only be necessary to have the patients spend four 
or six additional hours in bed daily. This can be secured by having 
them retire shortly after the evening meal, and not rise until late in 
the morning. A hot bath of five minutes' duration and a glass of 
hot milk or a glass of beer on retiring for the night encourage sleep. 
A cold douche or cold sponge, to the full length of the spine on rising, 
gives a vigorous morning start. In addition, an hour's rest in the 
recumbent posture in the middle of the day should be enjoined. 
The amount of work must be reduced. It is rare that this can not be 
done even in the most responsible positions. It should be needless to say 
that the condition of organic activity, if deranged, must be put to rights. 
Constipation, a sluggish skin, or inactive kidneys, if uncontrolled, will 
defeat the best general management. Large quantities of drinking 
water usually aid in several ways, and, as a rule, neurasthenics shun 
water. If these regulations can be instituted during a vacation, espe- 
cially one spent among new scenes, an additional advantage is gained. 

In the severer male cases an absolute separation from business and 
family is usually required, and a long sea voyage with a pleasant com- 
panion often works wonders. As a rule, the more outdoor air and 
recreation that does not entail effort, the better, but to put a neurasthenic 
on a bicycle or on long walks adds fuel to the flames. A carefully 
selected, nourishing, fattening, unstimulating diet is of considerable im- 
portance. If the scales show a gain of a few pounds, success is assured. 
Men, unless practically bedridden, do not respond favorably to the 
Mitchell rest-treatment. The enforced idleness and confinement to 
bed is rarely tolerated by them if they can possibly be about. 

In the severe female cases, and sometimes in young males or com- 
pletely prostrated men, we must have recourse to the full rest plan laid 



NEURASTHENIA. 601 

down by Mitchell. The details of this are furnished in all modern 
works on therapeutics and need not be repeated here. By this plan ex- 
penditure of energy is reduced to a minimum, strength is conserved and 
increased by the massage and electricity, and flesh is rapidly made by 
the constant feeding. There are several essentials in carrying out this 
procedure, and their neglect means failure. The first is isolation from 
relatives and friends, and the establishment of an entirely new and hope- 
ful atmosphere. In some instances the slightest infraction of this rule 
causes immediate relapse. Equally important is it to have an experi- 
enced and tactful nurse. 

Any amount of general hospital training does not make a good nurse 
for this class of patients or furnish the endless tact and self-repression 
needed to manage them. It is difficult to induce nurses, accustomed to 
grave operative cases and severe physical illness, to appreciate that the 
endless complaints and fault-findings of neurasthenic patients are symp- 
tomatic of their state and not merely petulant crankiness. It is also 
very important that the treatment take place in a suitable location, free 
from disturbing noises. The room and immediate surroundings of the 
patient must be bright and cheerful. If isolation with a suitable nurse, 
preferably one able to give massage, can be had, the other details of 
treatment are less important. The absolute milk diet does well in some 
cases, and is indispensable in a few at the beginning, but if food is 
digested and the bowels active it is immaterial what the patient eats so 
long as it is nourishing, abundant, and administered at frequent inter- 
vals. Sleep, usually disturbed, under the massage and forced feeding 
soon becomes sound and prolonged. Hot milk, an alcohol rub, or a 
glass of beer at bedtime is commonly a sufficient hypnotic. 

No scheme of treatment in neurasthenia is complete that ignores the 
mental element of the disorder. These patients are frequently impression- 
able, and particularly so as regards their own health and prospects. 
Their fears can not be laughed to scorn. They should be carefully esti- 
mated, fully explained, and then dismissed. It is not advisable to allow 
these patients to reiterate their complaints to the physician and the 
nurse, and the family must be instructed to refuse to hear or dis- 
cuss them with the patient. Encouraginy suggestions and hopeful as- 
surances constantly repeated have the force of hypnotic suggestion, and a 
very real therapeutic value. For this reason the physician must usually 
see his patient frequently. In this way the daily use of static electricity, 
hypodermic injections of strychnin or water, or any other objective ex- 
cuse, impresses the patient and permits and emphasizes the repeated en- 
couraging suggestions. With all the physical measures is to be continued 
a re-educational psychotherapy. Mental and physical tasks, activities, 
and work must be adjusted to the patient's abilities and capacities and 
this training must go forward with him for months and sometimes for 
years. 

Thus far nothing has been said about drugs, and there is very little to 
say. Iron and arsenic against the anemia, trional and bromid for the 
insomnia, laxatives for constipation, may be given. Strychnin in large 
doses, or bromids and sedatives in large doses, are ill-advised and 



602 NEUROSES. 

commonly harmful. The indications are to rest and to nourish, not to 
stimulate or to depress. Hy dr other apeutics, especially if carried on at a 
distance from home, yield good results in mild cases. It may be said 
that the treatment of neurasthenia requires judgment, tact, perseverance, 
and personal force of the highest order. When the neurosis is secondary 
to organic processes, its treatment is similarly second in order. Climatic 
conditions embracing windy low-lying stretches, altitudes above 3000 
feet, and fluctuating extremes of temperature are decidedly disadvan- 
tageous. As a rule, neurasthenics do best at the sea-level and preferably 
at the seaside in an equable climate. 



CHAPTER VI. 
PSYCHASTHENIC 

Occupying a middle ground between nervous diseases and out- 
spoken insanity, sometimes linking them together, are a large number of 
manifestations of reduced mental control or of limited mental weakness 
to which the term psychasthenia may be well applied. Such patients 
usually seek relief of the general practitioner or the neurologist and are 
generally considered as nervous or neurasthenic, hence the propriety of 
discussing them here. While their mental manifestations are analogous 
to those of neurasthenia, hysteria and actual mental alienation, in typical 
cases and in large numbers they furnish a fairly definite syndrome devoid 
of the irritable weakness and ready fatigue of neurasthenia, the stigmata 
of hysteria and the erroneous ideas of insanity. Naturally occurring in 
neurotic and degenerate individuals, it would be strange did they not show 
a mingling with or a development into the other psychoneuroses and 
psychoses. It is even stranger that such bizarre mental activity as is 
shown by psychasthenics may be of lifelong duration without essential 
variations and without forcing the patient into the field of insanity. 

Under the term psychasthenia may be grouped those conditions which 
have been variously termed fixed -ideas, obsessions, imperative conceptions, 
impulses, morbid scruples, phobias, doubts, agitations, feelings of strange- 
ness, feelings of changed personality, mental and motor tics, etc. In all 
there is a certain enfeeblement of psychological functions of protracted 
duration, and in all a clear recognition by the patient of the unreasonable 
nature of the act, idea, or condition, and of defective self-control. 

The fixed ideas, obsessions and phobias pertain to nearly every subject 
of human feeling and activity, and are all attended by a sense of dis- 
satisfaction, but rarely by great mental depression. We may, with Janet, 1 
classify the obsessions as those of sacrilege; of crime; of shame of self or 
person; and those of a hypochondriacal sort. For the phobias the Greek 
language has been searched to find sufficient names. Claustrophobia, 
fear of closed places; agoraphobia, fear of open places; amaxophobia, 
1 "Les Obsessions," Paris, 1903. 



PSYCH ASTHENIA. 603 

fear of vehicles; misophobia, fear of dirt; and a hundred others testify to 
the range of human feeling and the wealth of the Hellenic tongue. In 
many cases, however, the fear is vague and indefinable. Janet has labor- 
iously tabulated the phobias as: fears regarding the body; fears of ob- 
jects; fears of situations, physical and social; and fears of certain ideas. 
Under these heads he has listed over forty different varieties with in- 
numerable variations. 

These mental symptoms, while often recurring for many years in the 
same patient, are not continuous. Like the motor tics (see p. 606), which 
are merely the enactment of fixed ideas, they are intermittent, but of 
more or less frequent occurrence. Again, like the motor tics, these well 
called mental tics are prone to remain precisely the same for a given case, 
or when modified the change is either an evolution along functional and 
associated lines or a reduction to a part of the original morbid concept. 
These fears, impulses, etc., therefore, occur in attacks, crises and bouts 
with varying intervals of comparative calm. 

The origin of mental tics usually has relation to some emotional shock 
or striking experience, but their repetition may be determined by any 
object, circumstance, sound, smell or other suggestive factor, however 
remote. Finally, they may recur with almost spontaneous rhythm, like 
the running of a tune through the head. A locality where once a patient 
has experienced the mental anguish of an attack of claustrophobia is in- 
delibly associated with that episode and is usually shunned to prevent a 
recurrence. Such patients in a similar way may continuously narrow 
their opportunities and shorten their radius of action until they may finally 
confine themselves to the limits of the house or even to those of a single 
room. In the dread of contracting or transmitting a contagion some 
refuse to shake hands and finally to even touch articles or garments used 
or to be used by others, and all the time with the ready expression that 
they know it is all nonsense but that they cannot help it. In fear of poison 
they may prepare their own food or only partake of that first shared by 
others. Those impelled to crime take endless and often perfectly silly 
and inadequate but comforting precautions to prevent the act which all 
the time they declare they contemplate, yet feel they will never accom- 
plish, and as a matter of fact these morbid impulses never culminate in any 
serious crime. The whole story is the recurrence of the idea. Patients 
who are morbidly impelled to touch certain objects, to take steps in a 
certain manner, to turn in an exact fashion, to repeat words or lines when 
reading, to retrace a certain number of steps, do these things habitually 
and are made extremely uncomfortable, almost frenzied in extreme cases, 
if prevented. If any of their manoeuvres are foregone they describe 
feelings of unrest, distress, vague apprehension, and may be made very 
unhappy thereby, but will readily agree that there is no sense in their acts, 
fears, or worries, yet insist that they cannot control them. As a matter 
of common observation, however, they at times can and do control them- 
selves. In all its phases, therefore, this mental condition is one of incom- 
pleteness. There is about it a certain laughable incongruity quite ap- 
parent to the patient, who may only tell it of in a joking, shamefaced 
fashion. 



604 NEUBOSES. 

In the crises of obsessional attacks the patient may clearly manifest 
his perturbation of mind and its physical effect. Anguish and fear are 
shown in the countenance and in the attitude and actions. A dilated 
pupil, a pale face covered with perspiration, rapid pulse and respiration, 
are the physical concomitants of the mental agitation, but the patient 
does not lose consciousness, though the mental storm seems irresistible, 
and he experiences a feeling of relief on its termination. 

In the etiology of psychasthenia heredity plays an important part. 
Pitres and Regis in the tabulation of 100 cases could find but 20 in which 
there was no prenatal trace of nervous or mental instability; Janet in only 
8 out of 100. The great majority of psychasthenic individuals are clearly 
marked by the signs of degeneracy. As to sex, females preponderate about 
3 to 1. While no age is exempt, the most favorable period for the develop- 
ment of psychasthenia is between twenty and fifty, with the maximum at 
about thirty. 

The determining causes are almost innumerable, but importance at- 
taches to fatigues, excesses, traumatisms, infectious diseases and develop- 
mental and evolutional life periods. Gastric and cardiac disturbances, 
genital diseases and conditions, vertigos and other marked sources of self- 
concern bulk rather largely in the list. Freud 1 is disposed to regard the 
sexual element as pre-eminent if not invariably in operation in the causa- 
tion of psychasthenia as well as in hysteria. Psycho-analysis by the 
Freudians frequently uncovers some peculiar sexual experience which 
the patient may then be persuaded is the cause of his obsession and 
sometimes with complete relief, but there are other than sexual causes 
of psychasthenia. As emotional determinants we may enumerate the 
influence of strong religious emotions, the self -questionings of adoles- 
cence and sex relations, frights of all kinds, death in all forms, fear of 
all diseases, grief, bereavement, and deprivations. In a general way emo- 
tional states long continued are more potential than emotional shocks. 

The course of psychasthenia is essentially chronic and we cannot 
with propriety place a case in this catalogue that has not persisted for 
several months. The onset proves to be insidious the more carefully we 
analyze the mental features that precede its symptomatic appearance; 
in only a very few cases does it appear to come suddenly in the immediate 
wake of an emotional shock, and even here predisposing features are 
commonly well marked. A period of self- questioning, of mental rumina- 
tion, of premeditation is commonly crystallized into the particular ob- 
session that thereafter has a partial and sometimes almost complete domi- 
nation of the individual and which may last for the rest of life. Many 
psychasthenics regain their self-mastery almost completely, to relapse on 
some further provocative occasion, the condition being remittent, or it 
may actually intermit and recur in a modified form. Occasionally one 
idea will replace another of a similar nature. 

Physical states dependent upon such morbid ideas as defeat the proper 
manner of living — fear of food, of urination, of defecation, of sunlight — may 
powerfully modify the general health and furnish physical complications. 
Janet insists that psychasthenia being a psychological affair is not foreign 
to insanity, and out of 300 cases noted 23 who became definitely alienated 
1 "Wiener klin. Rundschau," 1899. 



PSYCHASTHENIA. 605 

mentally. The tendency shown by these cases was to the elaboration 
of fixed and systematized delusional states. 

The termination of psychasthenia frequently brings the individual to 
a condition of inertia and self-isolation. Many gain a relative mastery 
over their obsessions. A few make an apparently good and lasting re- 
covery. Remissions and relapses and intermissions are common. A 
small portion become absolutely insane. 

The diagnosis in a typical case is perfectly plain, but the associa- 
tion of fixed ideas, phobias and obsessions with neurasthenia, hysteria, and 
insanity, makes of the first importance a careful scrutiny, to determine the 
presence or absence of these states. The features of good physical and 
relatively of good mental health, aside from the obsession, are important. 
The absence of somatic and stigmatic indications of hysteria and neur- 
asthenia, and the fact that the patient fully recognizes the groundlessness 
of his morbid idea, are strongly indicative of the psychasthenic nature of 
the obsession. Any association of these diseases is of course possible. 

The prognosis in psychasthenia is sufficiently indicated in the state- 
ment of its course. However ludicrous this psychoneurosis may appear 
in minor phases, it may readily incapacitate an individual for the usual 
walks of life and finally by its domination make a close prisoner of him. 
Once recognized as an evidence of prenatal limitations the physician is in 
a position to understand that he is dealing with a deep-seated, inherent 
defect, and that a long struggle is in view for him and his patient. Yet 
many cases are manageable and a practical recovery may be often se- 
cured. 

The treatment of psychasthenia, aside from the prophylaxis, which 
embraces the control of parentage, etc., is physical and mental, but es- 
pecially mental. 

The physical treatment aims to discover and remedy any and every 
local or general deviation from health. It embraces the rules of hygiene 
and dietetics, measures of tonic and sedative medication, and directions 
for physical exercises. 

The mental treatment of psychasthenia is a far-reaching subject. 
It first of all requires a physician sure of himself, sure of his diagnosis, 
and well equipped to understandingly enter into the patient's feelings and 
to assist him by various mental crutches to regain his self-control and 
master his obsession. The patient in a certain profound sense requires 
re-education and his life must be simplified. He must have a definite 
purposeful occupation. He must practise self-control, and his discourage- 
ments must be explained and his courage supplemented by the advice 
and support of the physician. Many such patients find great comfort if 
their condition can be attributed to some physical cause the remedy of 
which is fraught with hope. Others can be best managed by a full 
analytical discussion of their symptoms and conditions. Others can be 
aided by the frequent use of some placebo, the taking of which arouses 
and repeats in their minds the helpful suggestions of the physician and 
tends to the maintenance of a hopeful expectancy. Every time they 
control their fears or impulses they gain strength to master themselves, 
and every time they yield they lose correspondingly. Electricity in its 
multitudinous applications, hydrotherapy, massage, are useful, but mainly 



606 NEUE0SE8. 

as an avenue of suggestive therapeutics, and when thus applied with the 
constant assurances of benefit do much good. 

Suggestion under hypnosis sometimes gives brilliant, but usually 
temporary, results. It cannot be made the sole reliance. Change of sur- 
roundings which have become charged with potential morbid suggestions 
and associations, the recreation of travel and the stimulation of objective 
interests, have great value. Everything must be done to change the self- 
centered, egotistic point of view. 

For further matter relative to psychotherapy as applicable to this 
condition the reader is referred to the portion of this book dealing with 
mental diseases. 



CHAPTER VII. 

MOTOR TICS. 

Tic, Maladie des tics, Mimic Spasm, Habit Spasm. — Recent 
French writers, following Tourette, make a sharp distinction between a 
tic and a spasm. After them, a motor tic is an action which is identical 
with movements of volitional intent, and contains, therefore, a psychic 
element which may be subconscious. It is a psychoneurosis, a variety 
of psychasthenia, and is accorded a separate description mainly by reason 
of its objective motor features, which are often confused with other dis- 
orders. The preceding chapter should be read in order to gain a fair 
comprehension of its nature. In facial tic attention is called to the wink- 
ing of the eye, exactly like that which excludes a flying particle of dirt; to 
the movements about the mouth and nose, identical with those produced 
by sensations of taste or smell, and to the occasional functional association 
with these of swallowing efforts, laryngeal motions, the production of suck- 
ing or smacking sounds, of grunting, and of articulate words, sometimes 
of an indecent character (coprolalia). A facial appearance that is expres- 
sive of some emotion, as of grief, pain, fright, or joy, may be repeated by 
the tic. Some cases, becoming more wide-spread, involve the neck and 
upper extremity so that attitudes and gestures are produced in con- 
formity with the underlying mental idea. These tics, of which blepharo- 
spasm is a type and coprolalia the extreme development, are more or 
less under the control of the patient, who can, by an effort of will, do 
considerable to repress them. After such repression ""tiquers" are 
likely to feel more or less vague discomfort and often yield to a regular 
spasmodic debauch, which seems to give them a feeling of relief. 
During sleep the tic completely subsides. Such patients frequently 
present a most marked neurotic heredity, and sometimes other neuroses, 
as writers' cramp and hysteria, or mental and moral obliquities are 
present. 



TICS. 



607 



Ordinarily, a tic is rapidly executed, and may be repeated with great 
rapidity from two to scores of times, when a lull occurs for a few min- 
utes, or perhaps an hour of quietude may intervene. Any excitement 
or embarassment promptly recalls and intensifies the morbid motions. 
On the other hand, any decided interest fixing the patient's attention 
interrupts the twitchings. The tic has a tendency to invade neigh- 
boring muscles of associated function, and frequently becomes bilateral, 
but is seldom symmetrical, excepting those tics more or less limited to 
the face, especially to the nose and mouth. While, ordinarily, the move- 





Fig. 246.— Facial tic. 



Fig. 247.— Mental torticollis. 



ments are abrupt and momentary, they may, in a part or the whole of their 
distribution in long-standing cases, present tonic features of greater or less 
duration. In some instances the eyelids are so firmly closed that the 
pressure upon the eyeball is painful. Rigidity in the lips is complained 
of at times as a feeling of stiffness, and the action of the zygomatics 
and buccinator may keep the angle of the mouth persistently retracted 
and elevated. The neck may be rigidly held in a given position. A 
somewhat similar spasm is often noted after Bell's palsy. It is, how- 
ever, always unilateral, the affected muscles are distinctly contractured 
(see page 125), and it does not so distinctly imply purpose. However 
violent the motor tic may be, as Janet insists, it never results in any 
physical hurt to the patient or damage to his surroundings. Its incon- 
venience consists mainly in making him conspicuous and self-conscious. 
Although motor tics may imitate useful movements and gestures, when 
once established they serve no useful end whatever. 

Etiology. — Youth is the preferred age for the development of tics, 
but adult life is not spared. An appreciation of the mental substratum 
of tics enables one to comprehend something of their genesis and in- 



608 NEUBOSES. 

tractability. There is no doubt that many cases of blepharospasm 
originate in some irritation of the ocular apparatus that forces the atten- 
tion of the patient into a groove leading to a mental and motor habit. 
These tics have for long been well called habit spasms. The term 
habit chorea, also applied to them, is misleading, though they mav be 
grafted upon a chorea as a sequel by suggestion. In the same way a 
protracted grief, chagrin, or ecstatic pleasure may, in one neurotically 
predisposed, furnish the subconscious factor for an expressional tic, which 
reproduces exactly the facies of the underlying idea, perhaps made 
grotesque by its unilateral distribution. The thread can sometimes be 
followed by covering the sound side of the face and trying to interpret 
the emotion expressed by the tic. Sniffing, swallowing, and phonation 
are merely the manifestations of functional association, and coprolalia is 
but the vocalization of the imperative concept that may be otherwise 
subconscious. A facial spasm is sometimes associated with neuralgia of 
the fifth nerve, and bears the distinctive and classical name of tic dou- 
loureax; the spasm, however, is secondary to the pain and sometimes ex- 
pressive of it. It is a grimace, but may persist as a true tic after pain 
ceases. A tic in the limited sense is not painful, though patients often 
complain of aches and tired feelings in the muscles affected by the pro- 
longed contractions of postural tics, as, for instance, in mental torticollis. 

Varieties. — Aside from the habit movements of idiocy and dementia, 
which constitute reversionary or degenerate tics, we may enumerate 
blepharospasm, facial spasm, spasmodic torticollis, mental torticollis, the 
latah of India, the myriachit of Siberia, the jumpers of Xew England 
and Canada. 1 

In mental torticollis 2 some deviation of the head is customary and 
is spasmodically maintained. Ordinarily, it ceases when the patient 
lies down or it can be controlled by a slight amount of manual pressure 
upon the head or face. 

Jumpers and the subjects of latah and myriachit execute any one of 
several commands or suggestions impulsively, often violently, and fre- 
quently against their apparent will. Thus, upon command, they may 
strike, jump, or unclothe themselves. 

Treatment. — In all cases of facial tic, after general measures, we 
are to look for and correct any peripheral irritation that can be asso- 
ciated with the seventh nerve. This is particularly the case in the dis- 
tribution of the sensory portion of the fifth, but irritation arising even 
at a distance, as in the intestines or pelvis, may maintain the tic, and 
when corrected the tic may subside. Pressure upon certain points in 
the distribution of the fifth, first described by Graefe, often checks the 
tic. The most usual one is at the supraorbital notch. In a general 
way they correspond to the tender points of Yalleix and the maxima 
of Head. AVe should always and repeatedly search for them carefully, 
going over the neck, shoulders, and upper chest, as they are sometimes 
distantly located. By exerting pressure upon such a part, the tic seems 

1 Jos. Collins, "Med. News," Dec. 11. 1897. 

2 Bompairs, ''These de Paris," 1894, and Brissaud, "Leeons," 1895. 



TICS. 609 

to be reflexly inhibited, and the habit is arrested, at least temporarily. 
By repeating the arrest frequently and for long periods, the habit may 
be fully broken. In the same way the use of faradic electricity will 
occasionally render service. For this purpose the muscles engaged in 
the tic should be thrown into powerful tonic contractions for a number 
of minutes, from five to fifteen. One pole taken in the hand and the 
other placed over the stylomastoid foramen, or on the particular facial 
branch indicated, makes a suitable arrangement. The patient may 
advisably keep a battery at hand and use it as often as the tic becomes 
marked. It for the time being teaches the muscle a steady contraction 
and perhaps favorably affects the mental state by the peripherally 
induced suggestion. At any rate such application is often followed by 
temporary marked relief, and, in fortunate cases, by practical cure. A 
sugar pill, to be taken with great exactness every thirty minutes, has 
served a good purpose by constantly reminding the patient of the phy- 
sician's suggestions, and recalling his attention to voluntary self-control. 

Finally, nerve-stretching may be employed. If thoroughly done, it 
induces paralysis for a longer or shorter time, but, unfortunately, a 
restoration of motor function usually is marked by the reappearance of 
the tic, for which the irritation in the healing nerve-trunk may be 
responsible. A tendency to relapse in these cases is marked. The 
deeper the mental tare and the more pronounced the neurotic back- 
ground, the less are they manageable. It is not impossible that sugges- 
tion, by reaching the subconscious element, may sometimes yield favor- 
able results. All varieties of retention dressings and appliances are at 
first apparently helpful, but shortly become irksome, unbearable, and 
harmful. 

In mental torticollis, Feindel 1 has reported good results by massage 
and exercises, the purpose of which was to build up the patient's self- 
control and mental stamina. With these he associated encouragement 
(suggestion) and general tonic measures. The exercise treatment em- 
braces two varieties of motor effort. First, the patient practises volun- 
tarily controlling the spasmodic muscles by keeping them at rest. 
Second, the affected muscles are alternately contracted and relaxed 
methodically a dozen times. These exercises should be repeated hourly. 
It is only by attacking the mental element, the obsession, that the psy- 
choneurosis can be managed and the various suggested measures are a 
means to that end. 

1 "Nouv. Icon, de la Salpet.." Dec, 1897; also Meige et Feindel, "Les Tics et 
leur Treatment," Paris, 1902. 



610 NEUROSES. 

CHAPTER VIII. 

HYSTERIA. 

Hysteria has been an interesting problem since the earliest days 
of medical thought. Unrecognized it occasioned the demoniacal " pos- 
sessions" of the middle ages, and furnished some of the martyrs of 
witchcraft and religious fanaticism. Affecting whole communities, it 
caused epidemics, allayed by appeals to St. Guy, St. Vitus, or other 
tutelary. It has been seen in the excited religious gatherings of all 
countries. As a disease it was long supposed to be limited to the female 
sex, and was attributed to vapors or other influences arising from the 
womb ; hence the name hysteria. Only in recent years have the en- 
demic and epidemic forms been understood, and the male found to share 
with the female in the liability to the psychoneurosis. For many years 
the mental element in hysteria was at least partially recognized. Moebius 
used the definition, " A state in which ideas control the body and pro- 
duce morbid changes in its functions." So far as the paralyses and 
contractures are concerned, English writers described them as " depend- 
ing upon idea." The studies of Charcot and his students placed hysteria 
upon a rigid clinical basis, and traced all of its manifestations to dis- 
turbances in the psychic sphere or in its substrata. 

Janet, who for twenty years has studied the psychology of hysteria, 
early contended that, " Hysteria belongs to a group of mental diseases 
of cerebral insufficiency." In a more recent pronouncement he says : 
" Hysteria is a form of mental depression characterized by the retraction 
of the field of personal consciousness, and a tendency to the dissociation 
and emancipation of the systems of ideas and functions that constitute 
personality." x He attaches great importance to the role of " amnesia," 
or absent-mindedness, through which certain experiences drop out of the 
field of consciousness, with a resultant change of personality which even- 
tually may become doubled or variously fragmented. 

Babinski, who would materially limit the physical manifestations of 
hysteria, says : " Hysteria is a special psychical state capable of giving 
rise to certain disturbances, which can be reproduced by suggestion and 
removed by persuasion." On this basis he erects a rather arbitrary 
criterion beyond which he sees nothing hysterical. 2 

The very interesting views of Freud trace all manifestations of hysteria 
to mental processes, more or less morbid, in which motives of shame 
have resulted in repressing the consciousness of certain experiences, 
which thus become unconscious or subconscious. In this state they 
tend to symbolize themselves, and hysterical manifestations more or less 
locally or functionally related arise. He traces the cause of the repression 
invariably into the field of sexuality, which with him is so wide as to 
embrace everything bearing any relation to sex impulses and feelings. 
Shame, modesty, parental and filial affection, and all sexual experiences 
and perversions lie within this domain. The practical part of his psy- 

1 " Major Symptoms of Hysteria," 1907. 

2 il Demembrement de l'Hysterie," etc., La Sem. Med., 1909 



HYSTERIA. 611 

chology consists in the contention that the motive for repression being 
once discovered, the patient can re-establish a normal mental attitude 
toward the circumstance, and its train of hysterical symbols then dis- 
appears. 

The purpose of citing these various views is to draw attention to the 
fact, in which they all agree, that hysteria is a mental disease, and that 
it must be so treated by the physician. 

In addition, there are a number of organic phenomena — disturbances 
of nutrition, trophic and vasomotor disorders — of a neurotic character. 
Hence, we class hysteria as a psychoneurosis. The absence of detectable 
primary changes in the nervous system is admitted on all sides, even in 
very chronic cases. 

In the presentation of the subject of hysteria the general outline of 
Charcot and his school will be followed. It is recognized that the type 
eases on which their descriptions were based are unusual, and even to 
some extent artificial, but they were complete. By understanding the 
full range of symptom groups one is enabled to recognize less complex 
instances of a similar nature, and hysteria is essentially a disorder of 
many fractional parts, any of which may be encountered practically 
alone. 

Etiology. — Hysteria in slight or severe form is one of the most 
common of nervous diseases. The age of puberty and the years of 
adolescence immediately following furnish the majority of cases. After 
twenty-five the frequency of hysteria declines and it becomes rare after 
forty-five. Before ten it is also uncommon, but children may develop it 
in very marked form even as early as two or three years of age The 
sensory features so common in adult hysterics are rarely encountered in 
children. Formerly considered almost exclusively limited to the female 
sex, later statistics go to show that males and females are affected with 
hysteria in nearly equal ratio. According to Marie, in the lower social 
levels males predominate; in the wealthier classes females are more com- 
monly affected. Hysteria is a disease of all countries and all races, but the 
Latin, Slav, and Israelite may be considered as particularly liable. 
Heredity plays an important part. Hysterics usually belong to neuro- 
pathic families. Hysteria in the mother is very frequently followed by 
hysteria in the daughter. More commonly, however, the transmission 
is by transformation from, or to, other neuroses and psychoses. Arthrit- 
ism or phthisis in the antecedents of hysterics plays the same part as in 
other manifestations of degeneracy. 

Inciting" Causes. — Emotional disturbance of any sort may initiate 
hysteria. Fright, grief, worry, chagrin, and every sort of mental and 
moral strain and shock are the common starting-points of this multiform 
disease. Freud, of Vienna, has laid great, too great, stress up^n the sexual 
factor in hysteria and allied psychoneuroses. Errors, shocks, emotions, 
excesses, abuses and emotions in the sexual sphere are sufficiently common 
inciting causes, but by no means the only or even the essential ones. 
Traumatism furnishes a large quota of hysterics, especially of the male 
sex, owing to their greater liability to such accidents. In all such circum- 
stances, unless consciousness be abolished instantly without preceding 



612 NEUROSES. 

anxiety or fright, the attending psychic states must be taken into con- 
sideration. As a practical fact, the likelihood of hysteria following 
trauma is in direct proportion to the intensity of the mental shock. The 
physical injury may be insignificant. Lightning-stroke, surgical wounds, 
and internal conditions, such as gastric ulcers, nephritic and hepatic colics, 
may act as causes. 

Intoxication by lead, mercury, sulphid of carbon, oxid of carbon, 
tobacco, morphin, cocain, and chronic alcoholism, or even a single 
alcoholic debauch, may induce hysteria. In many such cases these 
intoxications furnish a basis on which hysteria develops by the inci- 
dental action of some other provocation. Infectious diseases, such as 
typhoid, diphtheria, influenza, pneumonia, scarlatina, malaria, and syph- 
ilis, may provoke hysteria. It may occur in cachectic states due to 
chlorosis, diabetes, phthisis, and cancer. It is found as an associate of 
all organic diseases of the brain and spinal cord, frequently appearing 
in tabes, syringomyelia, and insular sclerosis. Either mental or physical 
overwork may cause it. Wherever people of suitable age are domiciled 
together, hysteria may become endemic through the force of imitation 
and suggestion arising from an initial case of hysteria or of some phys- 
ical disease. Schools, prisons, barracks, and large families may thus be- 
come affected. Usually in such instances there is great similarity among 
the cases. In this country, under the prolonged excitement and fervor 
of protracted religious meetings in rural districts, endemics of hysterical 
spasms and even of dancing, in all respects similar to the medieval 
epidemic dance of St. Vitus, have developed. Hysterical patients in 
hospitals may closely mimic all the symptoms and physical disabilities 
of other patients with whom they are kept in contact. In other cases 
they reproduce the manifestations of some disease with which, in their 
past experience, they have been made familiar. 

Symptoms. — The innumerable symptoms of hysteria, to follow the 
plan of the French writers, may be divided into two major groups : 
those which are essentially persistent, — the stigmata; and those which 
occur incidentally, are intermittent or transitory, — the accidents of 
hysteria. The stigmata are not necessarily present singly or in com- 
bination, but, once developed, tend to persist so long as the affection 
lasts. The accidents present the greatest diversity in different patients, 
but usually, if they occur repeatedly, tend to uniformity in a given case. 
Further, some hysterical accidents, as paralyses or contractures, may 
be of long duration, and, once thoroughly established, have the force of 
stigmata. Although the cases of major hysteria are comparatively rare 
it is only through a familiarity with the entire range of the disease, with all 
the details of the picture, that larvated, partial, and fractional states can 
be recognized. This is particularly true of the temporary or incidental 
features of this disease, and especially of the convulsions. 



HYSTERIA. 613 

STIGMATA OF HYSTERIA. 

The stigmata of hysteria are sensory, motor, and psychic. 

Sensory Stigmata. — In hysteria the sensory disorders are (1) of 
the negative variety, — anesthesias ; and (2) of the positive sort, — hyper- 
esthesias. They are usually both represented in a given case, but the 
anesthesias are the more important symptomatically. Owing to the 
heightened suggestibility of hysterics, merely searching for sensory 
changes may inaugurate or modify them, but even so their presence 
has its symptomatic value. 

Hysterical anesthesia may affect sensation in all its modes and 
tenses, including the special senses. The general cutaneous sensibility 
may be disaggregated so that only certain elements persist and a limited 
group of stimuli alone serve to arouse the sensorium, as in a thermo- 
analgesia that parallels the sensory dissociation of syringomyelia. The 
diminution of sensibility may be partial or complete, and often varies in 
the same patient within a very short time. Various degrees of anesthesia 
may likewise be found in different regions, and the anesthetic area 
represents remarkable variations of extent and distribution in different 
cases, and also in the same case at different times. Some form and 
degree of anesthesia is rarely lacking in hysteria that has existed any 
length of time, and often it is developed very early. It is obligatory 
to persistently search for it in every instance, but care must be exer- 
cised not to induce it by suggestion. As a rule, hysterics are themselves 
ignorant of their sensory deficiencies. The anesthesia may be (1) super- 
ficial, affecting mainly the skin and mucous tissues, or (2) it may involve 
the deeper structures. 

Cutaneous anesthesia may be absolute. Pricking, pinching, hot and 
cold bodies, produce no response. Some patients are merely analgesic, 
and this is the common defect. Less frequently there may be thermo- 
anesthesia or thermo-analgesia, and, most rarely of all, tactile sensations 
alone may be wanting. Very exceptionally the hysterical patient feels 
the faradic current in the anesthetic area or, more rarely still, presents 
an area insensitive to this stimulus alone. Complete anesthesia, hypes- 
thesia, and hypalgesia are the commonly encountered forms. The mucous 
membrane within the range of examination may show the same anesthetic 
modifications of sensibility. The buccal, pharyngeal, laryngeal, nasal, 
conjunctival, anal, urethral, and vaginal surfaces may be entirely insen- 
sitive or present dissociation of sensation. In the area of cutaneous and 
mucous anesthesia there is usually, if not always, a modified vasomotor 
change, so that prickings which readily draw blood elsewhere do not 
bleed. 

The deeper parts are frequently anesthetic. Bones, muscles, ligaments, 
and nerve-trunks may sometimes be pierced, twisted, wrenched, and 
contused without giving rise to distress or even provoking a localized 
sensation of any sort. The muscular sense for a limb may be abolished, 
so that with bandaged eyes the patient has no knowledge of its position, 
cannot estimate weights, recognize pressure, or feel fatigue. 



614 



NEUROSES. 



The Special Senses.— Taste and smell may be perverted, dimin- 
ished, or abolished. Certain sapid articles may fail to arouse the sense 
of taste, while others are still detected. The loss of taste is usually 
limited to a portion of the tongue and mouth. Hearing is often greatly 
diminished, but complete hysterical deafness is very uncommon. 
Kinne's test (see p. 65) shows the disturbance to be central. When the 
loss of hearing is pronounced, one commonly finds more or less anes- 
thesia in the auditory canal and on the same side of the head and face, 
but absolute anesthesia of the drumhead is exceptional. x 



Right. 




too 




Fig. 248.— Hysterical concentric contraction of visual field of right eye ; amaurosis of left eye (Tourette). 

In hysteria vision is very frequently modified, and some of the 
changes in this special sense are of the utmost importance for diagnosis. 
Complete blindness is very rare, usually of abrupt onset, a few days' 
duration, and sudden recovery, but vision is often reduced in one eye to 
counting fingers or less. Of greater frequency and of more importance 
are the lesser and commonly persistent defects. These consist of: (1) A 
reduction of the field ; (2) troubles of color perception, and (3) errors 
of accommodation. 

Contraction of the Visual Field. — In the great majority of hysterics 
the visual field is concentrically contracted. This is usually found 
bilaterally, but commonly more on one side than the other, and some- 
times only on one side. The defect, as in that of all the special senses, 
when unilateral or most marked on one side, usually corresponds to a 
unilateral distribution of disturbed cutaneous sensibility, but the opposite 
situation may be encountered. In total amblyopia the contraction of 
the field reduces it to zero. In a given case the retraction of the field 
is practically permanent, but it may fluctuate greatly. An epileptiform 
attack, fatigue of the eye, emotions, and variations of attention may 
modify its limits. Hysterical hemiopia and scotomata are so infrequent 
that they should always suggest an organic lesion. 

The dyschromatopsia is more characteristic of hysteria than the 
contracted field, which is also present in neurasthenia. In the normal 
eye the fields for the various elementary colors are not coextensive (see 
iChavanne, Paris, 1901, " Oreille et Hysterie. " 



HYSTERIA. 



615 



p. 64). In their natural order blue has the largest field, followed by 
yellow, orange, red, green, and violet. In hysteria not only are the 
fields for form and light perception contracted, but those for colors are 
also diminished, and to a proportionate degree. The important particu- 
larity is that the normal order is generally changed. The red field often 
exceeds the blue. When the color-fields are extinguished, they usually 
disappear in this order : violet, green, blue, yellow, and, last of cdl, red. 
Objects are then finally seen as grayish, and we have the condition of 
achromatopsia. 





J 80 /do 

Fig. 249.— Hysterical bilateral concentric contraction of visual fields (Tourette). 




Fig. 250.— Concentric retraction of visual fields for colors usually found in hvsteria. Red field inclosed 
thus: + + + ; white field, ; blue field, ; green field, -f — -| V (Souques). 



Accommodative errors in hysteria are sometimes encountered, by which 
near vision, particularly, is rendered faulty. To the same source have 
been attributed the monocular diplopia, polyopia, macropsia, and micropsia 
that are occasionally met. In this condition, with the opposite eye cov- 
ered, the patient fixes the gaze upon a pencil close to the eye. As it is 
withdrawn, its image doubles, and at a greater distance a third may ap- 
pear, and they all increase in size, and again diminish as the pencil ap- 
proaches. Errors of curvature in the cornea must be excluded to render 
the symptom significant. 



616 NEUROSES. 

It has recently been recognized that, aside from complete bilateral 
blindness, the various forms of hysterical amblyopia are not present in 
binocular vision. Even opening the unaffected eye, in the case of uni- 
lateral amblyopia, at once widens the contracted field (Parinaud). 
Patients who cannot read with either eye alone may do so readily with 
both. That the amblyopic eye sees is easily demonstrated. With a red 
glass over the affected eye a prism over the other doubles the image 
of a flame, and the red image, corresponding to the amaurotic eye, is 
distinctly seen by hysterics. Or, in a case of unilateral green-blind- 
ness, a prism doubles the image of a green object and both are perceived 
as green. Again, an eye that fails to detect everything but red, upon 
looking at a revolving Newton wheel bearing red and green, sees it to be 
whitish, as does the normal eye, proper cognizance having evidently been 
taken of the complementary green. It is evident, therefore, that the 
trouble is not in the eye or in the paths of conduction, but that, under 
ordinary circumstances, the impression fails to enter the field of per- 
sonal consciousness. These symptoms are unattended by any change in 
the retina or media. Spiller 1 insists that the lachrymal reflex remains 
in hysteria even when the eye-parts and the side of the face are anes- 
thetic, while in organic lesions the tears are not similarly secreted upon 
irritating the conjunctiva, as with a piece of paper placed under the 
lid. 

Distribution of Hysterical Anesthesias. — In a very small pro- 
portion of cases the anesthesia in hysteria involves the entire cutaneous 
and mucous extent. Usually it is limited (1) to one-half of the body ; 
(2) to areas of more or less definite geometric outline ; and (3) to dis- 
crete islets. 

Hysterical hemianesthesia is a common distribution of sensory de- 
ficiency. Ordinarily, it affects the left half of the body, and is sharply 
limited by the median line. If intense, the approachable mucous sur- 
faces on the same side are commonly also anesthetic. As a rule, the 
special senses — sight, hearing, smell, and taste — are blunted on the 
anesthetic side, but in some cases the special senses are affected on the 
opposite side. 

Anesthesia in geometrical areas is frequently encountered. An entire 
extremity or a band about an extremity may alone be anesthetic. The 
distribution may often be described as a sleeve, glove, sock, stocking, or 
drawers-leg: anesthesia. The outlines have no relation to the anatomical 
distribution of the nerve-trunks whatever, but are referable to functional 
groupings. They often have a superimposed relation to functional dis- 
turbance, as in cases of paralyzed or contracted limbs, diseased joints, or 
local injury. In hysterical amblyopia the conjunctiva, lids, and a cir- 
cular area about the eye are usually anesthetic. In hysterical deafness 
the auditory canal and concha are frequently insensitive. In hysterical 
aphonia the larynx may be anesthetic. 

Islets of anesthesia of peculiar and paradoxical outline are sometimes 
encountered. These may be many or few, and it often requires minute 
and painstaking search to find them. 

1 " Phila. Med. Jour.," May 17, 1902. 



HYSTERIA, 



617 



Peculiarities of Hysterical Anesthesia. — 1. In the first place, 
the outlines of limited hysterical anesthesias, excepting hemianesthesia, 
do not conform to the anatomical distribution of cutaneous nerves or to the 
sensory areas related to the vertebral segments, but rather to the mental 
association of functions, and probably to their cortical representations. 

2. The organic and tendon reflexes in hysterical anesthesia are not 
modified, as in organic lesions marked by insensitiveness. The pupil, as a 
rule, responds to light and accommodation and to pinching of the neck, 






Fig. 251.— 1, Most common disposition of hysterical anesthesia. Black spots represent hysterogenic 
(Dutil). 2, Hysterical anesthesia in geometrical segments (Tourette). 3, Hysterical anesthesia in 
disseminated islets (Pit res). 



even when the eye is amblyopic and the skin of the neck is insensitive. 
The abdominal, cremasteric, knee, and toe reflexes are not abnormal. The 
cardiac and respiratory reflexes to painful cutaneous stimulation are re- 
tained, even when an anesthetic zone is used. Sometimes a spurious 
ankle-clonus can be obtained. Other reflexes dependent principally 
upon sensation are abolished by hysterical anesthesia. The palpebral 
and pharyngeal reflexes disappear if the parts are insensitive. The 



618 NEUROSES. 

pharyngeal reflex is lost in ninety per cent, of hysterics. Tickling of the 
trunk or the plantar surface does not produce the usual responses. Buz- 
zard lays especial emphasis on the loss of the plantar reflex, with reten- 
tion of the knee-jerk, in hysteria. 

In many instances the knee-jerk is relatively increased, and often a 
slight clonus may be obtained at the ankle. There is also a tendency 
for a tap on the knee to induce jerking of the trunk or both limbs, in 
addition to the true knee phenomenon. 

3. The anesthetic zones are movable. Though they may persist for 
months, and even years, they are not absolutely fixed, and often are even 
capricious. A number of things may serve to promptly or gradually 
modify them. Hysterical attacks frequently change the distribution of 
the anesthetic zones, and sometimes are preceded by an increase in their 
size. During such attacks the anesthesia may completely disappear. 
Anesthetics or a dose of morphin or alcohol sometimes cause its tempo- 
rary disappearance. Hypnotic somnambulism and suggestion may dis- 
place anesthetic areas, and they may disappear during sleep. If the 
patient's attention be strongly fixed on an anesthetic area, it may mo- 
mentarily restore sensation. In the same way, as pointed out by Patrick, 
the boundaries of the anesthetic area may enlarge during the course of 
an examination, the attention in this case naturally being directed to the 
loss of sensation. The action of so-called esthesiogenic agents is supposed 
to be largely due to the attention and suggestion they invoke. By the 
application to the anesthetic areas of a great diversity of objects, such as 
metal plates, magnets, woods, metals, minerals, and gases, or by the use 
of electrical currents, especially faradism and static sparks, the anesthesia 
may be made to shift, sometimes to disappear, and often to transfer to 
the opposite side. Some patients are susceptible to one agent, some to 
another, apparently in proportion as their attention or fancy is captivated. 
When the anesthesia is transferred, it tends to return to the side whence 
it was displaced, but in doing so oscillates from side to side several times 
before finally locating in its old habitat. A transformation of tactile 
into visual sensation sometimes occurs. Binet first described this curious 
phenomenon. If letters, figures, or geometrical outlines be traced with 
the finger-nail or a pencil upon anesthetic skin areas, the patient can see 
them on a blank wall or screen. Fry x also found that if a colored 
screen were used, the patient described the tracing as surrounded by the 
color complementary to the one before her ; for instance, with a blue 
screen the figures appeared to be in a red field. 

4. It is a striking and paradoxical fact that hysterics are not 
disturbed by their sensory losses, and are usually entirely ignorant of 
them until deciphered by a medical examination. For instance, the 
small and delicate movements of the fingers ordinarily so dependent 
upon sensation may be perfectly performed by the anesthetic hand of 
the hysteric under the guidance of the eye. Apparently the motor 
image is called up and exteriorized through the motor paths. 

5. It has been noticed that a hand completely anesthetic to all 
forms of sensation would yet grasp a pencil or other familiar object, and 

1 "Jour. Ment. and Nervous Dis.," Aug., 1899. 



HYSTERIA. 619 

promptly indicate its use, when the patient's eyes were bandaged and all 
sensation denied. In the same way an anesthetic leg and foot may 
cause no incoordination in walking. These paradoxical features have 
usually been attributed to deceit and simulation, but are presented by 
similar cases the world over without possibility of collusion. 

6. The sensory disturbance is frequently located by topical or 
traumatic causes. The frequency of left-sided hemianesthesia is 
related apparently to the lesser strength of the left side. The super- 
position of sensory disturbance to inflamed joints or to injuries or to 
points of focused attention may often be noted. 

Hysterical hyperesthesias are very common. Neuralgic pains 
and other disturbance of sensation may occur in hysterics as well as in 
others, without having any special significance, but often from such a 
source or from a blow or from the mere fixation of attention, perhaps 
through misdirected solicitude of the physician, there develops & peculiar 
sensitiveness. This is usually circumscribed. It may involve a joint 
(Brodie's joints) or an entire limb, but is practically never generalized 
or even of hemiplegic distribution. It is often confined to narrow, 
superficial zones or points, as at the vertex, giving rise to the classical 
davits, about the breasts, along the spine, in the groins, and at the pit 
of the stomach. The glandular portions of the breasts, testicles, and 
ovaries may be similarly sensitive. Such sensitive spots are frequently 
found in the midst of anesthetic areas, and while the surface may be 
exquisitely sensitive to the touch of a finger, the pricking of a pin may 
cause no discomfort. It will frequently be found that if the patient's 
attention is strongly diverted, the area so intensely sensitive may be less 
sensitive than normal and entirely tolerant of firm and deep pressure. 
In the same way, by suggestion or the application of various inert sub- 
stances, the sensitiveness may be, at least momentarily, suppressed. 
There is always found, upon close investigation of such sensitive areas, 
paradoxical peculiarities similar to those in the anesthesias, and which 
serve to proclaim their hysterical nature. 

If such a hvperesthetic zone arises from or becomes associated with 
some mental storm, pressure upon it may serve to revive the memories 
in question and provoke a hysterical fit. It is then denominated a 
spasmogenic or hysterogenic point or zone. The mental character of hys- 
terical hyperesthesias is evident in their genesis and associations. Of a 
similar nature are the disagreeable or painful sensations provoked in 
rare cases by certain substances or by heat or cold. Paresthetic ting- 
lings, numbness, etc., are comparatively rare. 

Motor Stigmata. — The motor stigmata of hysteria must be sharply 
distinguished from the motor accidents to be considered later. The 
stigmata are usually unknown to the patient, and must be sought by the 
physician. Practically, they differ from the accidents only in degree, 
and show the substratum of more marked errors of motor control, which 
are likely to develop as accidents at any moment. In many ways they 
are indicative of the automatism which is one of the most marked 
features of the psychoneurosis. 

1. Movements in hysteria are retarded. The reaction time is in- 



620 NEUROSES. 

creased often for the simplest movement, and in proportion to the insen- 
sibility of the parts brought into play. The retardation, therefore, is 
closely allied to the anesthesias. It may be increased by diverting the 
patient's attention or diminished by concentrating his attention upon 
the given act. In automatic movements provoked subconsciously or 
under hypnotism the retardation disappears, showing its psychical nature. 

2. Movements are maladroit and incoordinate, unless carefully super- 
vised by the patient; and this, again, is proportionate to the anesthesia 
and the obliteration of the muscular sense. In automatic and subcon- 
scious movements the incoordination disappears. Partial or complete 
catalepsy and automatism in such limbs may be present if the patient 
can not see the limb or otherwise gain an idea of its position. 

3. Hysterical patients are often incapable of performing several 
acts simultaneously, as they are unequal to the division of attention 
thereby necessitated. 

4. Voluntary intentional movements are usually weakened. Patients 
who may in an automatic manner show great strength in the per- 
formance of customary and habitual tasks, when asked to make a 
test effort, as upon the dynamometer, register an insignificant amount. 
They appear incapable of willing an effort of which they do not possess 
the deeply graven motor image. The difficulty again is mental — the 
outcome of their diminished volition and attention. Amyasthenia is 
most marked in the insensitive parts, and foreshadows the paralytic 
accidents. 

5. In many hysterics there is a tendency to rigidities or con- 
tractures. It may be demonstrated in weakened or anesthetic limbs, 
and is often indicated by exalted reflexes. It may be provoked by an 
elastic bandage, deep massage of the muscles, sharp flexion or extension 
of joints, faradization, frictions, percussion, and suggestion, varying in 
different patients. The contractures thus induced invade both flexors 
and extensors, and fix the joint in a characteristic attitude, the same as 
that in the transient and spontaneous hysterical contractures. By 
similar means it can be caused to subside. Charcot denominated this 
state the diathesis of contracture. 

Mental Stigmata. — The mental stigmata of hysteria consist in a 
belittlement of memory and of will-power. The amnesia is sometimes 
due to the lack of mental concentration, — itself the outcome of the en- 
feeblement of volition, — and the loss of will-power is also frequently mani- 
fested in the impulsive acts and general want of self-control. 

1. Amnesia. — The forgetfulness of hysterics accounts frequently for 
their uncertain and contradictory statements, and has often unjustly laid 
them open to charges of deceit. In some instances the memory loss is 
systematized, — that is, it embraces a certain group of related facts pertain- 
ing to some person or event, while other contemporaneous incidents are 
recalled. In the same way a group of motor images may disappear, — 
such, for instance, as those for walking or writing or for articulate speech, 
— and astasia, agraphia, and motor aphasia result. In this way the recol- 
lection of a certain person may completely drop out of their minds, or 
they may lose all the words of an acquired language. In other cases 
the memory loss may be localixed ; that is to say, it embraces a given 



HYSTERIA. 621 

period of time. Frequently after a convulsive attack, sometimes in 
traumatic cases after the initial accident, there is a loss of memory for a 
variable period of time antecedent to the incident in question, or for a 
period both before and after the mental disturbance. Rare instances are 
recorded in which the amnesia has been total and complete for all acqui- 
sitions up to or during a certain period of life. Such patients begin 
again to speak and learn as children. In some cases acts and impressions 
are forgotten immediately. A book or a short story may be read re- 
peatedly with full interest and appreciation, but is at once forgotten. 
In all marked cases of hysteria there is some blurring of recent memories. 

The amnesias of hysteria are analogous to the anesthesias, and, like 
them, under the action of hypnotism or in subconscious states, may be 
demonstrated to be purely functional. The memory impressions do 
exist, and they can be revived. Recovered cases similarly regain the 
faculty temporarily lost. Out of localized amnesias a double personality 
may arise, as under similar circumstances the hysteric loses one group of 
memories and regains the other, alternating between the two. 

Aboulia implies absence of will-power. It expresses the impaired 
volition of hysterics, which reduces their powers of mental concentration 
and attention, and renders them vacillating, impulsive, and lacking in 
determination. In some cases it attains such prominence that they can 
not bring themselves to undertake the simplest task, such as dressing or 
undressing, and hesitate at the slightest obstacle. 

Impressionability or suggestibility is often extremely developed in 
hysterics, and practically constitutes a mental stigma. They are emo- 
tional and easily swayed, subject to the slightest influence and sensitive 
to insignificant impressions. The lack of will-power renders them of 
infirm and vacillating judgment, so that they often become dependent 
upon others to decide their slightest actions. The insistent, underlying, 
fixed idea thus controls them the more thoroughly. 

Simulation. — From inadequate knowledge of the disease, hysterics 
have been supposed to simulate for the pleasure of it, and to deceive 
for the satisfaction derived from notoriety. To a very slight degree this 
may be true, but the simulation and the deceit have their origin in 
misconceptions, in misconstrued impression, or arise from the failure of 
impressions to reach the field of consciousness. Hysterical young 
women are too commonly supposed to be erotic. This is sure to be the 
case if in their attacks they show emotional attitudes or actions that 
may be so interpreted. As a matter of fact, they are usually frigid. 
Introspection and self-concentration are fatal to the grand passion. 
Local anesthesias or hyperesthesias may completely destroy the genesic 
sense. It remains to be said that some hysterics do simulate purposely, 
and even cause wide-spread and dangerous lesions to maintain interest 
and sympathy. No fluctuation of temperature, skin lesion, or ulcerative 
process should be considered hysterical unless its fictitious production 
can be absolutely denied. 

ACCIDENTS OF HYSTERIA 
We come now to the more or less transitory features of hysteria, the 
accidents, chief among which are the hysterical attacks. These often 



622 NEUROSES. 

take the form of severe, intense, and prolonged convulsions. While 
uncommon in this country, they are occasionally observed in the most 
typical form. Ordinarily, however, the attack is partial or larvated. 
Only by an understanding of the extreme variety will we be able to esti- 
mate the simpler forms, which usually consist of isolated elements of 
the typical grande attaque of Charcot. 

Hysterical Convulsive Attacks. — The complete grand attacks, 
as studied and described by Charcot and figured by Richer, are infre- 
quent, but in some irregular or fractional form they occur in the very 
large majority of all cases of hysteria. Patients possessing spasmogenic 
zones may usually be thrown into a convulsion by firm pressure on these 
points, and during the seizure similar pressure again commonly causes it 
to subside. Emotional disturbances may cause the attacks or they may 
apparently come on spontaneously. 

The grand attack consists of a premonitory stage, followed by four 
periods : (1) The prodromal stage varies in different patients, but is 
uniform for the given case. Some patients are depressed, taciturn, and 
moody; others exhilarated, restless, quarrelsome, and talkative. Many 
have hallucinations of sight or of hearing, referred in the direction of the 
anesthetic side, and the insensitive areas may be increased. Usually, 
palpitations and vasomotor storms are observed. There may be nausea, 
hiccup, trembling, and the discharge of a large quantity of urine. 
The aura follows. This, ordinarily, consists of a painful feeling arising 
in the lower part of the abdomen, and develops into the sensation of a 
rounded body, which mounts upward, and, as it reaches the neck, gives 
rise to feelings of strangulation or suffocation — the globus hystericus. 
The face may flush, hissing is heard in the ears, throbbing is felt in the 
temples, objects turn dark before the eyes, vertigo occurs, and the 
patient sinks down, or even falls suddenly, unconscious, and the fit 
begins. In many instances the fit does not develop, and in a moment 
the patient is relieved, or the globus may last for hours without eventu- 
ating in a fit. Sometimes this train of symptoms is incited by emotional 
disturbance arising from insignificant irritation, or any strong mental 
impression may induce it. 

2. The epileptoid period closely mimics the features of an epileptic 
attack. There may even be an initial harsh noise or slight cry. The 
patient is rigid ; the face is pale, but promptly becomes red, and the neck 
is congested and swollen. Frequently the tongue is protruded or the 
teeth may be ground together. Biting the tongue and involuntary uri- 
nation are uncommon, but do occur. Usually the convulsion is most 
marked on the anesthetic side to which the face is turned. The tonic phase 
lasts two minutes or less, and is often attended by slow, rigid move- 
ments of wide range, with notable extension of the feet and supination 
of the hands or movements of circumduction, unlike anything seen in 
epilepsy. The fingers are usually clenched over the thumb, which may 
protrude between them ; the chest and abdomen are fixed and the body 
is rigid. This tonic phase is followed by a clonic phase, in which rapid, 
small oscillations begin in the rigid members and in the face. The sus- 
pended respiration reappears in broken, arrhythmical gasps and sobs, the 
chest and abdomen acting independently. Noisy movements of swallow- 



HYSTERIA. 



623 




Fig. 252. — Tonic phase, the tongue rolling from one angle of the mouth to the other (Richer), 



m 




m 



Fig. 253.— Schematic representation of the wide tonic movements (Richer). 




Fig. 254. — Tonic phase, circumduction movements of upper members (Richer). 




Fig. 255.— Clonic phase, schematic representation of clonic movements (Richer). 




Fig. 256.— Phase of resolution (Richer). 



624 



NEUROSES. 



ing and sonorous borborygmi are frequently produced. All the clonic 
movements are independent and illogical. This phase may last several 
minutes and gradually subside, the patient falling into a phase of resolu- 




Fig. 257.— Phase of resolution, retaining partial contractures (Richer). 




Fig. 258.— Posterior arc de cercle (Richer). 




Fig. 259.— Anterior arc de cercle (Knobloch). 




Fig. 260. — Lateral arc de cercle (Richer). 



tion, in which some rigidity may, however, persist. Stertor and froth- 
ing saliva may appear, and sometimes general twitchings or sharp spasms 



HYSTERIA. 



625 



may still agitate the patient at intervals. The pupil may not respond 
to light. 

3. The Period of Clownism. — After the phase of resolution of the 
epileptoid period has lasted a short time, the second period develops. It 
is made up of two phases, — (a) a phase of contortions, or illogical atti- 
tudes, and (b) a phase of wide-ranged, or grand, movements. The con- 
tortions of the first phase are usually steadily maintained for several 
minutes, thereby varying essentially from the grand movements of the 





Fig. 261. — Passional attitude of struggling with an 
assailant (Richer). 



Fig. 262.— Passional attitude of solici- 
tation (Richer). 




Fig. 263.— Zoopsia (Richer). 



Fig. 264.— Delirium of the fourth period (Richer). 



second phase, which are repeated with more or less rapidity. One of 
the most common and characteristic contortions is an exaggerated opis- 
thotonos, or arc de cercle. This may also be executed forward or later- 
ally. To these contortions succeed alternate flexions and extensions of 
the trunk or of the limbs, or rotations of the head. This phase is 
attended usually by violent outcries, and, in evident fear or rage, the 
patients tear their garments, grimace in a horrible manner, and put 
forth an astounding amount of strength against those trying to control 

40 



626 NEUROSES. 

them. In this phase they often bite, scratch, and strike at their at- 
tendants, apparently under the domination of the hallucinations of a 
fixed dream or delusional storm. 

4. Period of Passional Attitudes. — The third period is the gradual 
outgrowth and logical continuation of the second. The patient drama- 
tizes in pantomime the acts of the dream that embraces circumstances of 
the past life, or perhaps the incidents connected with the origin of the 
hysterical condition. Terror, love, gaiety, rage, eroticism, singly or by 
turn, animate the features and compel the attending attitudes and 
gestures. The acts, emotions, and attitudes of one attack are usually re- 
peated with fidelity at each succeeding crisis by a given case. If 
one knows the nature of the dream, it is easy to anticipate its manifes- 
tation. 

5. The period of delirium is a prolongation of the dream state of 
the third period. It still pursues and dominates the patient, who now 
talks in the delirium and verbally expresses his hallucinations, which 
usually have to do with disagreeable sights, animals, and acts. The 
panorama, in which red often predominates, unrolls from the anesthetic 
side. The passional attitudes may be occasionally repeated. The 
delirium may be gay, furious, sad, or obscene, and the language and 
actions correspond. After a varying time the hallucinations fade, sad 
memories may recur, with sobs and tears, and suddenly, or after a few 
moments' silence, the patient arouses, a little fatigued, and at once fully 
recovers his former conscious state. 

The duration of a grand attack is variable, but on an average requires 
from fifteen minutes to half an hour. The prodromal stage and the 
fourth period may be very long. The epileptoid period rarely exceeds 
three minutes ; the second period ordinarily lasts five to ten minutes ; 
the third is still longer. In some instances one attack follows another 
without appreciable interval, or some feature of the attack, as the stupor 
of the first period or the delirium of the fourth, may be prolonged for 
hours and days, constituting a status hystericus. The following table 
may serve to systematize the features of the grand attacks : 

{Mental disorders and hallucinations. 
Motor and S5H£ 
Aura, globus. 
f Onset. 
-ri .i , • -, • -, I Tonic phase. Slow movements and tetanic rigidity. 

Epileptoid period. j Clonic phase. Small, quick movements. 

[ Phase of resolution. \ Sopor, stertor. 

t> • -i n i ( Phase of contortions, arc de cercle. 

Period of clownism. j phage of ^ m0Yement ^ salaams . 

Passional period. ■{ Passional attitudes and actions. 

Period of delirium. ■{ Delirium, hallucinations, zoopsia. 

Modified or Partial Attacks. — The typical grand attack may be 
infinitely modified. It may be intensified or reduced in severity, but, 
what is of more importance, it may be disaggregated, and almost any 
feature of it may occur alone as a partial attack. These partial attacks 



HYSTERIA. 627 

may also be indefinitely prolonged in a condition of status. Some of 
the most commonly encountered ones follow : 

Vertiginous Attacks. — The premonitory vertigo, obscuration of vision, 
ringing in the ears, and sinking feeling may recur repeatedly, without 
other features of the attack. 

Globus attacks are among the most common of the larvated seizures. 
The patient suddenly feels the discomfort at the throat, or it may slowly 
appear, and only disappear after a considerable period. 

Epileptoid Attacks. — The attack may cease with the phase of resolu- 
tion belonging to the first period, or, recurring at this point, strongly 
simulate the epileptic status. The differential diagnosis is often ex- 
tremely difficult, the more so as epilepsy may aifect a hysterical subject, 
and convulsive manifestations of both neuroses may alternate. 

Tetanic Attacks. — The seizure may be limited to the first phase of 
the second period. The arc cle cercle suddenly appears, and may per- 
sistently endure, or to it may be added the clownism, with wide move- 
ments, giving, for instance, salaam attacks. Rage, joy, and other emo- 
tions may then modify the movements and the attitudes, and demoniacal 
or maniacal attacks are presented, in which the patient may be extremely 
wild and unmanageable. 

Attacks of ecstacy are manifestations of the passional attributes of 
the third period. With or without premonition or aura, the patient 
suddenly becomes motionless, and the face expresses astonishment, admi- 
ration, adoration, or stupor. Cataleptic features are often added. 

Syncopal Attacks. — After an aura or some feeling of discomfort the 
patient relaxes and becomes inert and apparently unconscious. The 
hands may be clenched or a tremor of the eyelids may indicate the 
spasmodic state. Respiration slows, the face may be pale or slightly 
flushed, but the pulse is unaffected. This attack may be prolonged into 
the sleep attack. 

Attacks of Sleep. — This lethargic or trance-like condition may follow 
several ordinary attacks, or some emotional storm may induce it. Its 
onset may be gradual, or sudden and apoplectic. The appearance is 
one of natural sleep, but careful search will often detect slight contrac- 
tures, as in the eyelids, which do not easily yield to the finger, in the 
ocular squint, or the position of the hands and feet. Frequently there 
is a marked tendency to catalepsy, and the limbs retain any position pas- 
sively given them. The pupils are sensitive to light, and, though gen- 
eral sensation seems abolished, it is only masked, as such patients fre- 
quently report all that has occurred during the sleep. The pulse-rate, 
ordinarily normal, may be diminished or increased. The respiration is 
usually shallow and reduced in frequency. The temperature may be 
normal, subnormal, or slightly elevated. Such attacks may last minutes, 
hours, or months, and terminate commonly by a convulsive attack, by 
laughter or tears, or a few delirious words. 

Somnambulic Attacks. — Some patients, under a sudden impulsion, 
start on long flights or make considerable journeys, in which they may 
travel great distances and consume many days. Finally, they come to 
themselves in great surprise at being from home, and may have no rec- 



628 NEUROSES. 

ollection of the intervening events. In a succeeding attack they may- 
recall everything that transpired in the first, and, by a repetition of such 
protracted attacks, build up a double existence or personality, or the 
morbid state may eventually completely displace the normal one. In 
lessened degree automatism and somnambulic attacks of short duration 
are not uncommon in hysteria. 

Motor Accidents. — Paralyses and Contractures. — Both the 
paralyses and contractures of hysteria are foreshadowed by the stig- 
mata of amyasthenia and the diathesis of contracture, of which they 
may be considered temporary exacerbations. They are frequently 
combined in a given patient, and even in a given limb. They may 
follow : (1) Convulsive attacks ; (2) mental impressions or shocks ; (3) 
traumatism ; and (4) various morbid states. It happens that after a 
convulsive attack a hemiplegic, paraplegic, or monoplegic palsy super- 
venes and tends to persist for a considerable time. The other in- 
citing causes mentioned act with less rapidity, and there is usually, 
even in traumatic cases, an intervening period of freedom from motor 
difficulties, — a period of meditation, as Charcot denominated it, or 
of autosuggestion, — lasting a few hours or several days. In addition, it 
is to be noted that there is no necessary relation between the severity of 
the physical exciting cause and the extent or completeness of the paralysis 
and contractures. They are relative, however, to the mental shock. 

Paralyses of hysteria are commonly marked by a sudden emotional 
onset, or they may gradually develop after some such moral storm. 
Rarely do they abolish every movement in a limb, and close obser- 
vation will usually detect slight evidences of voluntary or automatic 
motility. The antagonistic muscle-groups are equally affected and 
the limb is quite limp. There are vasomotor and trophic disorders 
in very exceptional instances only. The local temperature may be 
slightly reduced, and edema be encountered. Electrical and tendon 
responses are normal. There may be superficial or deep anesthesia or 
hyperesthesia. Variations of the extent and intensity of the paralysis 
follow various influences or occur spontaneously. Ordinarily, hysterical 
palsies terminate in complete recovery, but may last days or years. In 
some instances they are succeeded by contractures, or palsy and contrac- 
tures alternate. In rare instances the paralysis is clearly ideational, in 
that it occurs only for certain groups of voluntary movements, such as 
those of writing or walking. 

Hysterical contractures present loss of power, with persistent invol- 
untary rigidity, without modification of the electrical or tendon re- 
sponses. It is a rigid palsy. The affected limb is more or less rigid, 
the muscles are tense and firm, and the contractures persist during sleep, 
but yield completely during general anesthesia. Trophic disorders are 
rare, except in cases of several years' standing, when the muscles may 
be changed by actual fibrosis and permanent surgical deformities result. 
Ordinarily, there is superficial or deep anesthesia, or superficial sensi- 
tiveness. In slight cases the contractures may subside during sleep. 
Rare cases present exquisite sensitiveness and severe paroxysms of pain. 
Commonly the onset and termination are abrupt, but may be gradual. 



HYSTERIA. 629 

Contractures, once developed, show a tendency to protracted duration. 
They impress characteristic attitudes upon the limbs. The arm is usually 
adducted ; the elbov wrist, and fingers forcibly flexed. The hand, 
when alone affected, may be flexed into a fist, with thumb under or be- 
tween the fingers, or the hand may be extended or held in the writing 
position. The lower extremity is commonly extended in all its joints. 
Rarely, the foot is dorsally flexed. The muscles of the trunk are 
not infrequently contractured, causing deviations of the spinal column 
mimicking scoliosis and anterior and posterior curvatures. The toes 
may be extended or flexed. Many of these attitudes are transiently 
represented in the hysterical attacks, as shown in the figures on pages 
615 and 616, and in some sense hysterical contractures or palsies may 
be considered prolonged localized attacks, or as a hysterical status of 
fractional extent. 

Some of the more common varieties of hysterical motor accidents 
follow. 

Hysterical hemiplegia affects either side with about equal frequency. 




Fig. 265. — Hysterical contracture in foot and leg. 

Ernest Jones 1 in a tabulation of 277 cases found it approximately 55 times 
on the right to 45 times on the left side. The distal portions of the limbs 
are most affected. Instead of walking with the rigidity of organic hemi- 
plegia, the foot and leg are limply dragged along the ground, the advance 
being made by the sound side. Ordinarily, there is anesthesia of similar 
hemilateral extent or other sensory stigmata on the same or opposite side. 
Commonly the face escapes, and, when affected, the lower half is most im- 
plicated. Almost invariably limited contractures will at the same time 
be found, or they may predominate over the flaccidity or alternate with it. 

Hysterical monoplegias may be single or multiple. Their distribution 
may be unilateral or crossed. The face and limb on the same or op- 
posite sides, or both lower limbs, or all four limbs may be affected. 
Usually the paralytic member is not affected in its totality, and presents 
an anesthesia of greater extent than the paralysis and of characteristic 
geometric outline. The paraplegic variety may disturb the urinary con- 
trol, mainly through the anesthesia of the mucous surfaces. 

The face may be affected either by paralysis or contracture. In the 
paralytic variety the upper portion of the face usually escapes, as in 
brain-lesions. In the spasmodic variety the lips and tongue are most 
1 "Rev. Neurolog.," March 15, 1908. 



630 NEUROSES. 

affected, and an appearance of palsy on the opposite side is induced as 
the contracture drags the mouth to its own side. The spasm in the 
face and tongue is exaggerated by having the mouth opened and the 
tongue protruded. 

Torticollis may be due to contraction or to paralysis, and the vicious 
position of the head corresponds. Contractures may be confined to the 
eyelids, giving a false appearance of unilateral or bilateral ptosis. The 
rigidity and resistance of the eyelids and the depressed eyebrows dis- 
tinguish it from paralysis of the levator, in which the eyelids are 
relaxed and the eyebrow elevated. 

Contractures and paralyses of the ocular muscles are seldom seen, but 
do occur. Convergent strabismus may appear. Conjoined movements 
may be impossible upon voluntary effort, but take place inadvertently. 
Divergent squint, palsy, or contracture of a single rectus or oblique 
are not seen in hysteria. Pupillary stasis is not an extreme rarity. 
Karplus 1 contends that in the majority of cases during hysterical 
attacks the pupil does not respond to light, and that this may also be 
the case in minor attacks. 

Hysterical coxalgia may present all the attitudes of organic hip- 
disease, though abduction, outward rotation, and apparent lengthening 
are rare. The apparent deformity subsides under anesthesia, and the 
joint is found free and smooth. The joint also is not sensitive to 
percussion over the trochanter, or from the knee. Commonly there is 
an area of cutaneous sensitiveness, which is bounded by the iliac crest 
and Poupart's ligament above and a horizontal line below the trochanter. 
This may also be hysterogenic. Hysterical edema may mimic the local 
swelling and redness of actual disease, and, indeed, hysterical signs may 
be added to the true malady. 

Astasia abasia is a hysterical condition characterized by abolition 
or disturbance of the coordinate movements for walking and standing 
In bed or on a chair the patient may show full coordinate control of the 
legs, but may be unable to stand unsupported, or, if able to stand, is 
unable to walk. Some such cases, while unable to walk, can run, leap, 
hop, or climb with ease. The difficulty is due, as already indicated, to a 
systematized amnesia. 

Hysterical rhythmical spasms affect the limbs, face, or neck, 
causing movements, the same as those purposely executed in health, but 
steadily repeated with considerable force. They occur in attacks lasting 
from a few minutes or a few hours to several days. They cease during 
sleep, and apparently consist of a fractional part of a major attack. 
Among such rhythmical attacks may be named the nodding spasm, in 
which the head is nodded or shaken or rotated involuntarily, and so 
forcibly that it is impossible to check it by manual strength. The 
choreic dance or saltatory chorea, which played so important a part 
in medieval epidemics, is of this nature. Some patients move the arms 
as if using a hammer or other implement, and in general the rhyth- 
mical spasms show the dominance of a fixed idea. In a similar way 
the diaphragm may be affected, causing a peculiar, hoarse, barking cough. 

1 "Jahrb. f. Psych.," 1898. 



HYSTERIA. 631 

Sneezing or grunting may be repeated in more or less prolonged attacks. 
In very rare instances the movements mayclosely simulate the incoor- 
dinate, involuntary, arrhythmical action of Sydenham's chorea. 

Hysterical tremors are of great interest, and often present very 
difficult diagnostic problems. In hysteria, and as an accident of 
hysteria, we may encounter all varieties of tremor, not excepting the 
intentional form that is so striking a feature of insular sclerosis. 
Hysterical tremors may be localized or generalized, fine or coarse, rapid 
or slow, intermittent or persistent, and may last for months and years. 
The tremor of Graves' disease, of paralysis agitans, of senility, and of 
metallic poisonings may be exactly counterfeited by hysteria. In some 
cases the tremor comes on in spells or attacks, in some instances it is 
limited to the anesthetic side or to an insensitive member, and in gen- 
eral its exact relation depends upon the escort of hysterical stigmata. 
The combination of hysteria with the organic diseases which are marked 
by tremor is very common. This is especially true of multiple sclerosis 
and the metallic poisonings, Charcot gave the following classification : 

Hysterical Tremors. 

1. Oscillating tremors, ( Imitate paralysis agi- 
three to six per -J tans or senile treni- 
second. bling. 



A.{ 



Tremors, not increased by 
voluntary movements. 



eTiht ati to S S { **"*> <*W dis- 



ease. 



B. 



more per second. 

Tremors, occurring at rest 
or not, provoked or ex- 
aggerated by voluntary r 3. Intention tremors, c Imitate insular scle- 
movements which do not J five to seven per J rosis or mercurial 
accelerate their rapidity, ( second. ( tremor, 

but augment their am- 
plitude. 



Hysterical tics may be considered as fractional rhythmic spasms, 
occurring with more or less irregularity. Like tics in general, they 
have a purposive character, and are the expression of a fixed though 
usually subconscious idea. Winking, grimacing, shrugging, sniffing, 
coughing, movements of the hands, jerking of the legs, which may 
cause jumping, etc., are encountered. 

Sensory Accidents. — Painful Accidents. — Owing to their more 
insistent nature the sensory accidents of hysteria are nearly all of a pain- 
ful character. Sudden amblyopia and deafness have already been men- 
tioned among the stigmata, but may appear transiently as accidents. 

Hysterical cephalalgia may be deep-seated or superficial, in which case 
it is marked by a hyperesthetic zone. In rare instances it is most pro- 
nounced in the eyeball. It is likely to occur in periodic attacks, es- 
pecially toward night, may be attended by vomiting and prostration, 
and is sometimes intense. It may be confounded with luetic headache, 
migraine, the pain of cerebral tumor, even with that of meningitis. 

Hysterical pseudomeningitis is occasionally encountered and may 



Q32 NEUROSES. 

deceive the elect. It may present malaise, loss of appetite, pains in the 
head, increasing to an insupportable intensity and leading to delirium. 
Vomiting, rigidity of the neck and extremities, fever, vasomotor streaks, 
and convergent squint may be added. Only a history of antecedent 
hysteria, an active pupil, a regular pulse, an absence of the dissociation 
between temperature, pulse, and respiration, and the presence of hys- 
terical stigmata will enable a diagnosis if spinal puncture gives negative 
results. 

Spinal irritability and tenderness are frequent, and sometimes consti- 
tute the dominant symptoms. The sensitiveness is exquisite, and may 
be localized over a few vertebrae, simulating Pott's disease, or extend 
the length of the spine. In many instances it is especially severe over 
the coccyx. The lightest touch, even the contact of the clothing, may 
be painful, and the patient can neither lean back in chairs nor lie on the 
back. Usually, if the patient's attention can be completely distracted, 
the sensitive zone is found tolerant even of vigorous, deep pressure. It 
is analogous to the hysterical hyperesthetic joints and localized hyper- 
esthesias. 

Visceral neuralgias are often marked by superimposed hyperesthetic 
stigmata, and may give rise to the suspicion of appendicitis, gastric 
or intestinal ulcer or malignant disease, or ape the crises of tabes. 

Hysterical angina pectoris may exactly trace the features of steno- 
cardiac attacks. In some cases it may attend an actual organic lesion, 
but usually there is no evidence of cardiac disease, and hysterical 
hyperesthesia in the precordial region is present. Such attacks are 
likely to occur in the night, and may have their starting-point in a dream. 
Often they are preceded or followed by emotional disturbance of a 
hysterical sort. Generally, the attacks are of short duration, but may 
persist for several days in a sort of status. The prognosis is not entirely 
favorable, in view of the fact that it is impossible to absolutely exclude 
an organic condition during life. 

Visceral Accidents. — Respiratory Apparatus. — Associated with 
laryngeal paralysis and anesthesia, aphonia is encountered. It usually 
appears suddenly. The patient may whisper or execute low tones. 
Sonorous cough generally, and sometimes singing, may remain unim- 
paired, showing the ideational disturbance of vocalization and the 
systematized defect. Such patients may talk in their sleep with a voice 
of normal qualities. The laryngoscope may show the vocal bands 
unduly separated or approximated. Mutism is more clearly a cerebral 
defect, a systematized motor-speech amnesia. It may or may not be 
attended by aphonia. In rare instances agraphia has been present, but 
ordinarily the patient writes, gestures, and otherwise readily expresses 
ideas. The mouth parts usually are entirely mobile and free, but 
sometimes the tongue is contractured and can not be protruded. 
Hysterical stammering has also been recorded. Mirror speech is some- 
times hysterical. The patient enunciates words backward. Repeated 
more or less rhythmic cries, sobs, barks, hiccups, sneezing, laughter, 
grunts, and various noises are met with, of which the type is the 
hysterical cough. They are often attended by sensations of a foreign 
body in the nasal chambers or pharynx, and appear usually in attacks 



HYSTERIA. 633 

occurring at various intervals, and presenting a variable duration. They 
cease during sleep. The cough is very frequent in hysterics of pubes- 
cent age, and may appear as the sole manifestation of the disease. A 
mental, moral, or physical shock may induce it, or abnormal conditions 
in the nasopharynx may be the starting-point. Acute inflammation or 
adenoids should be suspected. 

Hysterical dyspnea may be (1) of sudden onset, due to laryngeal 
spasm ; (2) it may result from contracture or paralysis of the diaphragm, 
and (3) it may consist of an extremely rapid breathing, reaching 60 or 
100 respirations a minute. The laryngeal spasm is a rare accident, but is 
very alarming when it does occur, and has resulted fatally. Ordinarily, 
relaxation occurs when a certain degree of apnea has been reached. In 
the form marked by rapid respiration there may be no discomfort or 
effort, and the pulse is usually normal in rate and character. 

Pulmonary congestion and hemoptysis are not very rare. Usually 
there is dulness at the apex, which may strongly suggest phthisis, but 
lacks the cachexia and temperature, and the sputum is free from bacilli. 

Digestive Apparatus. — Hysterical anorexia sometimes reduces the 
patient to the lowest level of inanition. Patients reach such a degree 
of emaciation that they are practically living skeletons, and life is all 
but extinct. A fatal termination is quite possible. The origin of this 
state is in some fixed idea of suicide or of expiation. It may even 
arise from some trivial fear, as of growing too fat. In some iustances 
an esophageal spasm causing dysphagia leads to the refusal of food, or 
it may follow vomiting. Hysterical vomiting occurs in attacks which 
may last days, weeks, and months. Food is simply regurgitated or 
violently expelled after a short stay in the stomach. Even fecal vomit- 
ing has been observed. 1 Sometimes there is anuria, and the gastric 
ejecta will be found to contain a corresponding amount of urea. The 
amount of vomiting and urinary excretion often alternate in close rela- 
tion. In another form the esophageal spasm is temporary or more or 
less prolonged in the form of globus. Tympanites may appear in asso- 
ciation with contracture of the abdominal muscles, and cause a phantom 
tumor, or, if attended by hyperesthesia, the appearances suggest peritonitis. 
Intestinal spasms are of frequent occurrence in hysteria, and may even 
produce prolonged obstipation by an anorectal contracture, which is often 
attended by severe pain and great sensitiveness. It may be mistaken 
for rectal stricture. 

Urinary Apparatus. — In addition to the anuria and partial sup- 
pression of the urine attending or alternating with hysterical vomiting, 
and the discharge of large quantities of limpid urine of low specific 
gravity in the prodromal period of the attacks, or after any of the acci- 
dental crises of hysteria, the amount and relative proportion of some of 
the urinary constituents may be greatly modified. Tourette and Catheli- 
neau found that the urine of hysterics in the inter par oxistic periods of 
their disease was practically normal. Hysterical storms or temporary 
accidental crises, such as convulsive attacks and the various forms of 
hysterical status, like rhythmical spasms, delirium, or trance, presented 
a marked change in the urinary excretion. There is (1) a notable 
1 Bregman, "Neurol. Centralbl.," Oct., 1901. 



634 NEUROSES. 

diminution in the fixed residue ; (2) the urea is reduced about one- 
third ; (3) the phosphates are decreased about one-half of the normal 
output for twenty-four hours. Upon examination they found (4) that 
the normal proportion of the alkaline to the earthy phosphates was 
altered. Ordinarily, it is in the ratio of alkaline 3 to earthy 1, but 
immediately after or during such attacks they become about equal. It 
is necessary to secure a twenty-four-hour collection on which to base 
such estimates, and it should embrace the period of the hysterical storm. 
Further, (5) in status lasting several days they observed that the dimi- 
nution of urea lessened toward the end of the attack, and as it reached 
the normal amount the status yielded. Although any of the points 
may be presented in other than hysterical conditions and even in 
epilepsy, the combination of the first four may be taken as very charac- 
teristic. Many hysterics are troubled with frequent urination, which is 





Fig. 266. — Dermographia in a male hysteric. 

especially aggravated if the mucous surfaces of the genitals or of the 
bladder are hyperesthetic. Mathieu *■ and Babinski assert that polyuria 
is generally, if not always, hysterical. In short, that diabetes insipidus 
is a hysterical manifestation, but this opinion cannot be maintained. 

Hysterical fever may be continued, remittent, or intermittent, and 
usually, if not always, is found in female cases. After an interval of 
a few days, or perhaps only after many months, it may disappear sud- 
denly. The temperature may attain a high range — 105° or 106° 
are not infrequent, and 110° and higher have been recorded. 
Usually the physical state shows no corresponding febrile disturbance, 
but in some instances the tongue is heavily coated, there is headache, 
depression, sweats, and general phenomena of fever. Emaciation is 
very unusual. Commonly hysterical fever is unattended by other hys- 
terical accidents, but it may be associated with pulmonary, meningeal, 
and peritoneal symptoms, and lead to mistakes. The intermittent 
form may suggest malaria. In the diagnosis of hysterical fever all sources 
of infection and hidden suppuration must be carefully investigated and 
simulation rigidly excluded. 

Trophic and Vasomotor Accidents. — The trophic accidents of 

i " Prog, med.," Feb. 18, 1899. 



HYSTERIA. 635 

hysteria are of recent recognition. They are few in number, and are 
but rarely encountered in severe degree. Here also simulation must 
be excluded. Babinski denies all these accidents to hysteria because 
he cannot produce them by hypnotism. On the skin, erythematous 
or vesicular eruptions are the most common manifestation, and the 
vesicular form may go on to ulceration and produce persistent scars. 
Even cutaneous gangrene has been recorded. Cutaneous hemorrhages 
in the form of bloody sweats have followed severe emotional disturb- 
ances. In some historical cases they have given rise to the stigmata of 
the crucifixion or been attributed to the finger-prints of the devil. 
They are usually preceded by great pain in the parts. Bloody tears 
and bloody discharges from the mamma or from the lungs are of a 
similar nature. Some hysterics show transitory periods of dermog- 
raphism. Neurotic edema, which may be red, blue, or white, and heat 
asphyxias similar in appearance to those of Raynaud's disease, may 
persist for many days, and usually ap- 
pear in parts otherwise hysterically 
affected. 

The hysterical breast is of rare oc- 
currence, but furnishes a source of 
much apprehension and misapprehen- 
sion. Suddenly, or within a few hours, 
one or both breasts enlarge, and are 
sensitive, painful, and hot. The skin 
may even be reddened. The nipple is 
turgid and sometimes erect. The glands .,. „._ „„..„, M „*Z^ flll -, ,„h 

o o tig. 2b/.— Hysterical contracture ana 

are firm to the touch, but not edema- edema of the hand, lasting several months. 

-. 7 . . . Index-hnger not affected. Gauze used to 

tOUS, and the hypersenSltlVeneSS IS USU- prevent nails cutting into palm. 

ally extreme. The enlargement may last 

several days or several months, and, if one-sided, may lead to suspicion 
of abscess or new growth. When bilateral, the condition has sug- 
gested pregnancy, especially as a milky fluid may ooze from the nipples. 

Fibrotendinous contractures in muscles the seat of persistent 
hysterical contractures have already been noted. Muscular atrophy 
has been observed by a number of reliable observers. It has its seat 
in the muscles of a paralytic or contractured member, and rapidly 
develops. Within a few days the muscular masses may lose a third or 
a half of their volume. The condition then remains stationary for a 
long time, and finally recovers. There is a quantitative loss in elec- 
trical excitability proportionate to the muscular shrinkage, but the 
reaction of degeneration does not occur. 

Course. — The course of hysteria is essentially chronic. Sensory 
stigmata have been known to persist for a lifetime, although accidents 
had long ceased to occur. It should be looked upon as a mental state 
which is likely to persist when once established, and as constituting a 
real disability, which may be partial or total. The various accidents 
may occur transiently, repeatedly, or persist for months and years, and 
must be individually considered in connection with each case. Under 
proper management hysteria is usually a manageable disease. Many 
cases get instant relief under certain mental and moral influences. 




636 NEUROSES. 

Prognosis in hysteria is clouded by the probability of recurrence 
under the action of inciting causes that otherwise might be trivial inci- 
dents. Many patients make substantial gain and consider themselves 
well, when an exhaustive examination discovers numerous persistent 
stigmata. These may be considered subjective recoveries. It is excep- 
tional for well-developed cases of hysteria to regain absolute health. 
Children and youths make better recoveries than older subjects. Major 
hysteria after the age of forty presents very poor prospects of complete 
recession. Many of the accidents of hysteria and some of the stigmata 
are capable of instant disappearence, many of the disabling features 
are easily controlled and dissipated, but the fact remains that the cura- 
bility of hysteria has been greatly overstated. 

Diagnosis. — The diagnosis of hysteria loses many difficulties if it 
is clearly distinguished from neurasthenia, emotional disturbances, and 
wilful deceit with which it has been commonly confounded. They have 
nothing to do with hysteria properly considered, but may complicate it. 
While hysteria is polymorphous, and may mimic all other maladies, in 
that very fact lies its detection. There is in it always an excessive or 
paradoxical element. No disease, when well developed, is so distinctly 
marked and stigmatized. The most reliable and consistent features in 
hysteria are the mental characteristics and the psychic stigmata. 
Next in frequency and importance are the sensory stigmata, among 
which the disturbance of the color-fields by contraction and inversion 
is common. Anesthesias in islets or geometrical outlines are practically 
demonstrative of hysteria. The movability or motility of anesthetic 
areas under various influences is found in hysteria alone. Among the 
motor stigmata the contracture diathesis and the ideational loss of power 
for systematized movements, as shown in astasia or agraphia, while 
strength is normal in other respects, declare the hysterical state. 

Some hysterical accidents are diagnostic. The typical hysterical 
seizure should be mistaken for nothing else. In the partial and much 
more commonly encountered seizures, attacks of ecstasy, of sleep, and 
of somnambulation are very distinctive. A careful examination of the 
palsies and contractures, taken with the ordinarily associated and usu- 
ally superimposed sensory stigmata, should disclose their hysterical 
nature. The rhythmical spasms are the property of hysteria alone. 
The tremors must be deciphered from the context of hysterical mani- 
festations and confirmed by the exclusion of organic processes. The 
same is true of tjie intestinal accidents. In the condition of the urine 
during and after paroxysmal manifestations we have a valuable index. 
Eeduction in total solids, especially in urea and phosphates, with the 
inverted proportion of alkaline and earthy phosphates is, perhaps, only 
found in hysteria. 

Once the suspicion of hysteria is entertained, a painstaking examina- 
tion of the patient should confirm or banish it. The greatest danger 
arises from failing to appreciate the limitations of hysteria and allowing 
its presence to interrupt careful search for organic disease of which it 
may be a secondary expression. Too often, when hysteria is recognized, 



HYSTERIA. 637 

the physician is content to attribute every symptom and complaint to 
the psychoneurosis. Hysterics may have phthisis, Bright'? disease, 
cerebral hemorrhage, typhoid fever, and hip-disease, as well as other 
persons. In every hysterical case the individual must not be forgotten 
or actual disease overlooked. 

Treatment. — Recognizing in hysteria a mental disturbance princi- 
pally, the treatment must be mainly psychic. This point of view 
may at once strengthen and weaken the physician. Unless he has a 
clear conception of the power of mental therapeutics, he is likely to look 
upon all measures as mere placebos and to lack faith in their value= 
Xot confident himself, he fails to inspire confidence in the hysterical 
patient. The game is lost before it is begun. It is the self-confidence 
of the charlatan or the fanatical belief of the " Christian Scientist " that 
now sometimes succeeds when well-informed physicians fail. Expectant 
attention and hopeful anticipation have cured hysteria in all ages, and 
are potent measures to-day. Methods are usually successful in propor- 
tion as they are novel to the patient, strike the fancy, and stimulate the 
imagination. This serves in itself to distract the hysteric from the rut 
of his fixed ideas, and, if the assurance of help and cure is added and 
constantly repeated by suggestion, it tends to supplant the morbid con- 
dition. A great moral impression or a mental shock may terminate 
hysteria at once or may greatly aggravate it. Treatment may be 
considered (1) as general, applicable to all manifestations of the disease ; 
and (2) special, regarding the manifestations of individual cases. 

General Treatment. — The first consideration is, if possible, to 
decipher the fixed idea that dominates the patient. This is easily done 
when the hysterical syndrome originates in some serious mental storm 
or personal experience. In other cases it can be inferred from the 
hysterical manifestations, and occasionally it is constantly expressed in 
some worry or apprehension. In many cases, however, it is a subcon- 
scious idea. It may have arisen even in a dream, or it may be so 
intangible that it never is fully formulated in the patient's conscious- 
ness. Sometimes, from motives of shame, or modesty, or morbid con- 
scientiousness, it is studiously concealed. The so-called psycho-analysis 
of Freud concerns itself especially or solely with this view of hysteria, 
and in an endless search for some sexual item rarely fails to find it. 

AVhen once the end of the tangled skein is in the physician's 
hands, his task is to modify or destroy the fixed idea, and thus remove 
the source of morbid mentalization. Too often family and friends 
support the patient's morbid view and exaggerate the gloomy pros- 
pects, adding fuel to the flames by anxious solicitude and thinly 
veiled or openly expressed fears. In the highly suggestible con- 
dition of hysteria their constant presence and their consciously or 
unconsciously reiterated depressing suggestions counteract all possible 
good at the hands of the physician. The very locality in which the 
disease has developed constitutes a forcible reminder of its present and 
prospective woes. Unless the surroundings, companions, and visitors 
of a hysteric can be absolutely controlled, it is usually impossible to 
manage the patient. It is for this reason that isolation and separation 



638 NEUROSES. 

from everything associated with the patient's morbid past is usually the 
first and most essential requirement of treatment. Under new circum- 
stances the statements of the physician regarding the trivial nature of 
the dominant idea or his orders to dismiss it and his assurance of cure 
carry a weight and force that are not immediately destroyed by other 
more constant and less wholesome influences. The very fact of isola- 
tion is a profound influence that can readily be guided into a hopeful 
and helpful channel. A visit from an anxious mother or solicitous 
friend may, in a few minutes, destroy all advantage and recall the morbid 
past with added intensity. This plan of treatment can often be put in 
the form of the Weir Mitchell rest-cure, and requires the same con- 
ditions already indicated in the treatment of neurasthenia (p. 600). 
Mild cases, especially in the young, can sometimes be well managed by 
a long journey with a sensible and not too sympathetic companion, or by 
a protracted visit to friends or relatives properly informed of the atti- 
tude they should maintain toward the patient. 

Hypnotism in its concentrated form is a dangerous measure and only 
of occasional service. In the hypnotic state the patient may readily 
disclose the hidden or subconscious idea, and it may at once be attacked 
and destroyed by countersuggestion. In the same way progressive 
improvement or immediate relief from the various conditions present 
in the patient may be suggested. Hypnotism may, however, precipi- 
tate a latent hysteria, and patients hypnotized for the removal of trivial 
hysterical symptoms have, in the hypnotic state or immediately after it, 
bloomed out in all the manifestations of major attacks or developed pro- 
tracted paralyses and contractures. In other cases hysteria restrained 
by hypnotism has recurred with added force when the seances were dis- 
continued, and Fere goes so far as to consider hypnotism but a transfor- 
mation of hysteria. It should be held as a last resort. 

It goes without saying that anemia and general states call for such 
remedies as are ordinarily beneficial, and local disease presents exactly 
the same indications as in non-hysterical patients. 

Special Treatment. — The convulsive attacks can frequently be 
stopped by a dash of cold water, by a sharp command, by pressure on 
hysterogenic zones, and, if other means fail, by inhalations of ether. 
Their repetition depends upon conditions which must be met by the 
general measures previously indicated. Paralyses and contractures are 
among the most permanent accidents when once established, and become 
actual stigmata. If taken early, they can usually be managed. Mas- 
sage, electricity, and repeated assurances of their early cure and of their 
insignificant importance is usually sufficient if the friends, in the way 
already described, do not defeat these measures. After a long duration 
they may require the full isolation treatment. Contractures of years' 
standing may be followed by fibrotendinous contractions only amenable 
to surgery. Anesthesias and hyperesthesias can be modified by a num- 
ber of influences of the esthesiogenic sort. Faradic and Franklinic 
electricity often act very readily to reduce and completely dissipate the 
field of disturbed sensation. Various objects, metallic, wooden, etc., 
active or inert magnets, have the same influence. It is all a matter of 
concentrating the fixed and hopefully expectant attention upon the 



EPILEPSY, 639 

parts. In the same way these measures are useful in the palsies and 
contractures. Spinal irritation, so called, when once well marked, 
usually requires the isolation and rest treatment, but sometimes the 
actual cautery or flying blisters, or other heroic and hence impressive 
measures, succeed in removing the hypersensitiveness. Aphonia and 
mutism require treatment of a similar sort. A faradic electrode intro- 
duced into the larynx or pharyngeal cauterization has succeeded almost 
instantly in some cases, but lasting benefit usually follows persistent and 
repeated suggestion of steady improvement, coupled with various sug- 
gestive manipulations of the parts. Laryngeal spasm and hysterical 
cough or sneezing, or diaphragmatic spasms, generally can be interrupted 
by having the patient or a nurse forcibly pull on the protruded 
tongue. Laryngeal spasm in rare instances may require anesthesia or 
even tracheotomy, but, fortunately, apnea is commonly followed by 
relaxation of the spasm. Dysphagia from esophageal spasms is often 
relieved by passing the stomach-tube and demonstrating the permea- 
bility of the gullet. Vomiting is sometimes benefited by lavage of the 
stomach and the mechanical introduction of food, but assurance of 
improvement and suggestion must be added to all these measures. 

Finally, it is the physician who is most sure of himself and of his 
diagnosis and has a distinct idea of the mental side of hysteria who 
best succeeds with general or special treatment. 



CHAPTER IX. 

EPILEPSY. 

Epilepsy has been the subject of medical description since the 
earliest times. It was known to the ancients as the sacred disease, 
morbus saeer. In colloquial English it is called the " falling sickness." 
Its most characteristic manifestation shows forth in the derivation of 
the name "epilepsy," which implies being seized upon. The seizing 
has been variously attributed to mythological deities, to the possession 
of devils, and to vapors and humors arising in the body. Focal epi- 
lepsy, or Jacksonian epilepsy, resulting from cerebral injury or disease, 
may be omitted from the present consideration. Epileptoid attacks arising 
from alcohol, lead, and uremia, and the eclampsia of parturients have no 
necessary relation to the epilepsy now in question. Epilepsy can scarcely 
be considered a distinct disease. It is a syndrome of nervous and mental 
symptoms appearing under a variety of pathological states. In many 
instances it is associated with morphological cellular changes in the cor- 
tex. In maDy more cases the anatomical basis still escapes detection. 
So commonly is epilepsy presented by neuropathic and psychopathic 
strains, and in those physically or mentally defective, that in itself it 
may be considered a presumptive indication of degeneracy. It is statis- 
tically proved that there is more than one epileptic for every four hun- 
dred of the population in this country. 



640 NEUROSES. 

Etiology. — Heredity plays a very important part in the causation of 
epilepsy. Arthritis, syphilis, phthisis, inebriety, insanity, and neuroses 
are common in the antecedents. Epilepsy appears frequently in suc- 
ceeding generations, and may descend directly from parents to children, 
but is more likely to be indirectly propagated by way of collateral 
branches. The heredity is most often by transformation from other 
neuropsychic disease. Thus, hysteria, epilepsy, and idiocy may follow 
in successive generations. Epilepsy among cousins is more frequent 
than among brothers and sisters, where, however, various neuropathic 
equivalents are frequently encountered. Consanguinity plays no part 
unless it brings together individuals of similar nervous or mental defect. 

Epilepsy may appear at any age, but it is distinctly uncommon for 
it to commence after the age of thirty. Epileptoid attacks after that 
age should always awaken a suspicion of gross organic brain, heart, or 
kidney disease. Syphilis is the usual cause of such seizures from thirty 
to forty-five; after forty-five we encounter the degenerations of senility, 
vascular changes, and accidents. The very great majority of cases of 
epilepsy develop under twenty years of age, and the pubescent period, 
between twelve and seventeen, contains the greater proportion of them. 
Very frequently epilepsy begins in infancy. Munson 1 publishes a chart 
based on 2732 cases admitted to the Craig Colony, which shows the dis- 
ease to have appeared within the first year of life in 225, the largest 
number in any one year. The incidence then rapidly falls to the tenth 
year, when it again mounts throughout the adolescent period, gradually 
descending after twenty. Convulsions during the first and second den- 
titions, incited by any febrile, septic, or toxic cause, may be followed by 
epileptic attacks at puberty. In some cases, beginning as eclamptic 
attacks in infancy or early childhood, epilepsy follows, with more or less 
periodical attacks from that time. Some families present numerous 
deaths from infantile convulsions, and epilepsy sometimes develops in 
those who escape. Nocturnal enuresis, pavor nocturnus, and epilepsy 
may appear in the same case, apparently replacing one another. It is 
necessary to carefully exclude from this consideration that large number 
of cases in which cerebral injury is present or brain defect arising from 
intra-uterine, birth, or postnatal causes. Such instances usually present 
evidence of cerebral lesions in some form of palsy, and are considered 
in Part III. Males are somewhat more commonly affected than 
females, with a ratio of 20 to 16, according to Spratling. Munson 2 
also conclusively shows that the life expectancy is greatly reduced in 
epilepsy, the average duration of the disease in 555 cases being 17.58 
years. Lung diseases, including pneumonia, phthisis, and pulmonary 
edema, are the most common causes of death, followed by status 
epilepticus, series of attacks, and accidents occurring during fits, or 
states of epileptic automatism. No doubt the severe pulmonary con- 
gestion present during severe attacks induces pulmonary suscepti- 
bilities. 

Inciting Causes. — The alleged inciting causes of epilepsy, by 

1 " Med. Kecord," Jan. 8, 1910. 2 Loc cit. 



EPILEPSY. 641 

their number and relative harmlessness, reinforce the presumption of a 
necessary predisposing defect, in the field of which they may become active. 
The hereditary considerations, the usual evidence of degenerac}^ and the 
common onset of the disease at developmental epochs all speak of a vicious 
organization unequal to the shocks of ordinary life and the demands of 
growth. In some cases, however, it is impossible to fix upon any pre- 
disposing state. 

Toxic agents, such as alcohol, lead, mercury, tobacco, chloroform, 
ether, morphin, cocain, etc., have been accused of inciting epilepsy. 
Alcohol is certainly competent to do so. The first fit may follow a 
drinking bout. Other toxic conditions arising from the intestinal tract 
or due to defective elimination through the kidneys may act as inciting 
causes. The infectious diseases, such as the exanthemata, may furnish 
the starting-point for epilepsy. Typhoid fever is causative in some 
instances. Syphilis may be causally related to epilepsy in various ways : 
(1) As a hereditary factor ; (2) through the malnutrition of the sec- 
ondary period ; (3) by local encranial disease ; and (4) Fournier thinks 
there is a peculiar syphilitic variety of epilepsy appearing late in the 
luetic history. Head injuries may produce focal epilepsy, but sometimes 
set up the common form of the disease. In the Franco-Prussian War, 
as a result of 8985 non-fatal head injuries, 46 cases of epilepsy devel- 
oped, only about § of 1 per cent. All things considered, head injury 
must be considered as a rare cause of epilepsy. Reflex irritations due 
to nasal growths, intestinal worms, pelvic disease, genital abnormality 
or disease, masturbation, and eye-strain are occasionally sufficient to 
provoke epileptic attacks and to cause their repetition. Sensitive scars, 
decayed teeth, and ingrowing toe-nails have also been brought into this 
list. In fact, any local peripheral cause of constant nerve-fag may, 
in those of unstable organization, serve to upset the nervous apparatus. 
Physiological states, like menstruation and childbirth, may incite epilep- 
tic attacks in those predisposed. In female epileptics, the menstrual 
periods are very frequently the occasion of attacks. Mental shocks, 
particularly fright, may cause the first fit. Some epileptics have a fit 
upon the incidence of any emotional disturbance. 

Pathology*. — It would be impossible within reasonable limits to 
give the numerous theories that have been advanced regarding the 
nature of epilepsy, or to discuss at length the various locations assigned 
the morbid action resulting in the fits. Suffice it to say that the 
presence of mental symptoms, sometimes the limitation of the attack 
to unconsciousness alone, the experimental demonstration of cortical 
excitability, the usual organic basis of Jacksonian fits, the recent find- 
ings of changed cortical structures in some cases, and a recognition of 
the supremacy of the cell in the doctrine of the neuron theory, all com- 
bine to declare epilepsy a disease of the cerebral cortex. 

It must be admitted that at present the most careful search fails in 
many cases to detect any histological changes known to be morbid. 
This is only another way of stating our ignorance of certain patho- 
logical processes and the limitations of present methods of" research. 
When a patient dies as the result of repeated convulsions, venous and 
sinus engorgement, minute hemorrhages, and more or less extensive 

41 



642 NEUROSES. 

cerebral ecchymoses merely evidence the recent paroxysms. Lesions 
of longer standing have been frequently found, such as meningo-en- 
cephalitis, widely disseminated tuberous sclerosis in the cortex and the 
great ganglia, and diffuse sclerosis of the convolutions. Much impor- 
tance was once attached to such hypertrophic sclerosis affecting the 
cornu ammonis or appearing in the bulb. Chaslin, Fere, and many 
others have repeatedly found neuroglial proliferation. Bloch and 
Marenesco have described vascular and perivascular changes in the 
cortex. Van Giesen has demonstrated changes in the large pyramidal 
cells of the cortex and in the neuroglia in two cases in which portions 
of the cortex were removed by operation. Bleuler, 1 in twenty-six 
epileptic brains, found a definite, wide-spread hypertrophy of the neurog- 
lial bundles lying between the pia and outermost nerve-bundles. This 
change was not proportional to the severity or duration of the disease 
or relative to the mental degradation of the patients. In fifty-four non- 
epileptic brains similar changes were not found. Ohlmacher 2 draws 
prominent attention to persistent thymus and enlarged intestinal glands. 
Clark and Prout 3 describe wide-spread changes in the cortical cells, 
especially of the second layer, consisting of deformities, absence of 
chromatic substance, and swelling of the nucleoli with tendency to loss 
of the nucleolus under the section knife. Donath 4 shows that cholin 
is usually present in the blood, which, with other products of metabolism, 
such as ammonia and kreatinin, may act to bring about the attack. The 
blood shows an excess of eosinophile cells which diminishes in the three 
days preceding an attack 5 and returns to its maximum within ten hours 
after the attack, often being of subnormal number during the attack. 
Turner 6 lays stress upon the apparent lack of full development of many 
cortical cells and the persistence of subcortical cells indicating imperfect 
differentiation and growth. Additionally he describes groups of shrunken 
cells and acute cellular changes similar to those produced by ligating 
cerebral arteries in animal experiments. On the part of the blood he 
notes an excess of blood platelets and various forms of intravascular 
clotting and cortical hemorrhages. 

Symptoms. — The most striking symptoms of epilepsy are the 
" attacks " or fits and their modifications and equivalents. Of equal 
importance are the postepileptic states and the mental and physical 
conditions of epileptics. 

Epileptic Attacks. — Prodromes and Aurse. — Many, but by no 
means all, epileptics have some distant or immediate premonition of 
the attack. Friends, nurses, and attendants upon epileptics often learn 
to anticipate an attack by temperamental or facial changes that are 
unnoticed by the patients themselves. These may be present several 
hours, or even several days, before the convulsive explosion. Fore- 
runners of a motor sort are grinding of the teeth in sleep, twitching of 
the eyelids, face, or extremities, tremors, and restlessness. Some epi- 

1 "Munch, med. AVochens.," No. 33, 1895. 

2 ' ; Bull. Ohio Hosp. for Epileptics," 1898. 

3 " Boston Med. and Surg. Jour.," April 23, 1903. 4 " Med. News," June 28, 1895. 

5 Morselli and Pastore, " Biy. Sperirn. di Frenat.," 1906. 

6 " Br. Med. Jour.," March 3, 1906. 



EPILEPSY. 643 

leptics complain of tingling in the extremities or on the surface of the 
body ; others have peculiar sensations on the tongue or in the nose, a 
tickling of the palate, or disturbances of smell or taste. Others have 
photophobia or brilliant muscse. Ringing in the ears, genital excite- 
ment, respiratory oppression, vague discomfort, mental stimulation or 
depression, unusual irritability or gaiety, are some of the various pre- 
monitory conditions. Some patients look unusually pale ; others present 
a suffused, puffy countenance ; and temporary erythematous and urticarial 
eruptions have been seen. Much as these more or less prolonged pre- 
monitory conditions vary among themselves, they are comparatively 
uniform and constant for a given case. 

The aura is the particular motor, sensory, or psychic feature that 
immediately announces the attack, and may be considered its initial 
symptom. In some instances it represents an abridged attack. It may 
recur for years unrecognized, until a fully developed fit indicates its true 
character. An aura of some sort occurs in fully one-half of all cases 
of epilepsy. Motor aurce may consist in a sodden limited muscular 
contraction or tremor, similar to the signal symptom of Jacksonian fits, 
and of only momentary duration. Automatic movement, and even a 
series of coordinate acts, may introduce the generalized attack. A 
patient scratches at the pit of the stomach, or winks his eyes, or 
moistens his lips with his tongue, or makes a few swallowing efforts, 
starts forward or backward, rotates upon his vertical axis, coughs spas- 
modically, springs up, or rolls his eyes to one side, following with his 
head and body. Unconsciousness at once follows, and the full fit occurs. 
Many epileptics have sensory aurce. A peculiar sensation is described, 
commencing in the feet or anywhere in the extremities, or in the abdo- 
men, especially at the pit of the stomach. It mounts upward, and con- 
sciousness usually fails as it reaches the upper part of the chest or the 
neck and head. In some instances it strongly suggests the globus of 
hysteria. One patient describes it as a " nagging feeling," and it usually 
is of an indefinite and indescribable sort. Visual and auditory sensa- 
tions are the most frequent of those that relate to the special senses. 
Those of taste and smell are very rare. Uniform and persistent aurse 
of taste and smell are so commonly symptomatic of temporal lobe dis- 
ease, and particularly of the uncinate gyre, that convulsions so intro- 
duced are frequently called uncinate fits. Some epileptics hear certain 
sounds of a pleasant or startling sort ; sometimes it is a distinct voice. 
Others describe everything as turning black or dark before their eyes ; 
some have phosphenes or bright flashes ; and in exceptional instances a 
definite picture is presented, such as that of persons or animals, which 
may rapidly approach or recede. 

Jackson first called particular attention to the psychic aurce, which 
are as vague and varied as those of a motor and sensory character. A 
sudden recollection or the instantaneous review of a lifetime, a certain 
fixed idea or doubt, may announce the convulsion. Sometimes it is a 
rapidly growing mental depression, a fervor, a feeling of mental exal- 
tation or weakness, irritable impulses, gaiety, rage, or quarrelsomeness. 



644 NEUROSES. 

Another group of aune are called visceral, but are, for the most part, 
sensory or motor manifestations referred to the various organs. Pre- 
cordial pain, violent cardiac palpitations, respiratory anguish, laryngeal 
spasm, weight at the pit of the stomach, vomiting, colics, and sudden 
imperative demands to evacuate the bladder or bowels are the principal 
ones. Cerebral aurce, such as sudden pain in the head, vertigo, stam- 
mering, and paraphasia, have been noted. 

Lewis has noted an elevation of body temperature during the aura, 
and Voisin has observed increased temperature in the limbs in which 
the aura originated. Fere and Franck have noted an increase of 
arterial tension before the fit, and the writer has obtained a sphygmo- 
gram showing the same thing. All these considerations indicate that 
the aura is of cerebral origin, and serve to indicate the portion of the 
brain most at fault, just as does the original symptom in Jacksonian 
fits. They should assist in mapping out the functions of the so-called 
cortical areas of latent lesions. 

Epileptic fits vary greatly in different cases, and usually a patient 
presenting severe convulsions also has slight or abortive attacks. We 
may consider (1) the complete attack, (2) the incomplete attacks, and 
(3) the equivalents of epileptic attacks. 

The complete convulsion, preceded by an aura or not, comes on 
suddenly, consciousness and sensibility are instantly lost, and the patient 
falls. The fit presents three distinct periods : (1) one of tonic convul- 
sion ; (2) one of clonic convulsions ; and (3) a period of stertor. 

The tonic stage opens suddenly, with all the muscles of the body 
in tetanic rigidity. It results that the patient not only falls, but is fre- 
quently violently thrown down. At the same time, the sudden tetanic 
muscular grasp of the thoracic cage and the fixation of the laryngeal 
apparatus give rise to a cry that is practically never verbal. Some- 
times it is a shriek; more often it is an expiratory guttural noise. The 
face is at first pale, but rapidly becomes congested and cyanotic, because 
respiration is inhibited. The eyes are fixed, often turned up or to one 
side or convergent, and the pupils are rigidly dilated. The dilatation 
is proportionate to the severity of the attack. Contracted pupils may 
sometimes be seen at the onset of the attack and again at the beginning 
of the stage of stertor. Minute vascular ruptures in the skin, mucous 
membrane, and conjunctiva often occur. It is probable that similar 
vascular accidents take place in the internal viscera and in the brain. 
If the hand be placed on the tonically contracted muscles, a thrill or 
vibratory impulse will be detected, such as is occasioned by excessive 
voluntary efforts. The tonic period is one of apnea, and only lasts one 
to two minutes at most. It may last only a few seconds. The tongue 
is frequently thrust between the teeth, and may be lacerated. The head 
may be slightly turned or retracted, the trunk is rigid and usually 
straight, the upper extremities, flexed at the elbows, are held close to the 
trunk, the fists are clenched, or the fingers may be made into a cone or 
spread by the interossei. The lower extremities are commonly rigidly 
extended. Complete symmetry of movements and position of the limbs 



EPILEPSY. 645 

is exceptional and quite frequently the lower limbs are partially flexed. 
It is at this stage usually that the spasm of the abdominal muscles ex- 
pels the contents of the bladder, sometimes those of the rectum. The 
vascular strain is extreme. 

The clonic period is in some sense a continuation of the tonic 
stage. The muscles relax, and again suddenly contract. The limbs, 
body, face, and all movable parts are agitated by the sudden sharp 
twitchings, which cause the face to grimace horribly, the jaws to grind 
together, often lacerating the tongue and cheeks, the eyes to jerk in their 
sockets, the air to be noisily forced in and out of the chest, churning 
the saliva in the mouth and throat and forcing it through the teeth and 
lips in a bloody foam. The arms, legs, and head beat against the 
ground. The clonic movements, at first rapidly repeated, gradually 
become less frequent, but maintain their force and vigor to the very last 
movement. The respiration, dominated by the clonic spasm, is ineffi- 
cient ; the asphyxia and cyanosis persist; the cardiac movements are pre- 
cipitate; the arterial tension is intense. This stage lasts from one to live 
minutes, and terminates in full relaxation, in which the bladder and 
rectum, if not emptied in the tonic period, may allow their contents to 
escape. The body and face are covered with perspiration, the tempera- 
ture mounts two or three degrees Fahrenheit. The clonic movements 
may be bilaterally synchronous, but have no suggestion of purpose, and 
are unmethodical and incoordinate. 

The Period of Stertor. — The relaxation in which the clonic stage 
ends is usually marked by deep stertorous breathing and continued un- 
consciousness. The patient lies inert, just as the convulsion left him, 
profoundly comatose, and may perish at this time, smothered by the bed- 
clothes or by similar mishap. After a few minutes, perhaps after a 
half hour or more, he opens his eyes and regains partial control of 
himself, without any knowledge of what has happened during the attack. 
If the attack take place during the night, the stertorous period may 
gradually merge into natural sleep, and the patient may be entirely 
unconscious of the occurrence of the fit. Usually the fit leaves the 
patient more or less confused, fatigued, sore, strained, and subdued for 
several hours or for a day or two. 

While the typical fit presents all of these symptoms, it may be infi- 
nitely modified. The tonic period may be instantaneous only. The 
clonic movements may be confined to the face, upper extremities, or 
lower limbs. The cry, urination, stertor, or bitten tongue may any or 
all be lacking. The convulsion may be most marked on one side, and, 
indeed, exact symmetry is uncommon. The only constant feature is 
disturbed consciousness, but unconsciousness does not in itself constitute 
a fit, though it may practically constitute an equivalent. 

Epileptic attacks often occur during the night, and in some instances 
only during sleep, giving rise to the clinical variety called nocturnal 
epilepsy, which may last for years without being suspected. Fits are 
likely to occur just as the patient is getting to sleep, or just as he is 
awakening in the morning. They may be induced by emotion, espe- 



546 NEUROSES. 

cially fright. Fatigue, coitus, menstruation, and child-birth may pro- 
voke them. Trepsat l notes that the last days of the menstrual flow and 
the two or three succeeding days are those on which the fits are most 
likely to occur, and that the menstrual periods are commonly marked in 
epilepsy by mental stimulation, or depression with irritability. In most 
cases, however, convulsions take place without adequate traceable cause. 
Some patients have them very frequently, and with considerable regu- 
larity ; others have them at irregular intervals ; and others may have 
but two or three during a lifetime. In aggravated instances they occur 
in groups, several taking place within a day. Such groups frequently 
follow an interval more than usually prolonged, or succeed a period of 
bromid repression. 

Occasionally, the patient, without recovering consciousness, has fit 
after fit, and in this way a series of hundreds may occur. This consti- 
tutes the status epilepticus, the gravest form of epileptic paroxysm. It 
consists of (1) a period of incessant convulsions, and (2) of a period of 
prostration and collapse ; but sometimes death occurs in the convulsive 
stage. Usually, after the fits have continued for several hours, or even 
for several days, they become less severe, and finally cease, and collapse 
ensues. During the convulsions the respiration and pulse are acceler- 
ated and the temperature may reach 104° or 105°, and even rise higher, 
until death occurs. The individual fits of the status epilepticus are 
rarely of the severest variety. The stupor is punctuated more or less 
regularly by convulsive attacks of moderate force, and the status may 
even be made up of the limited attacks of the incomplete variety, such 
as vertigos, delirium, stupor, coma, cough, hiccup, and various psychic 
states. The collapse of epileptic status may be so profound as to reach 
a fatal ending. 

Incomplete Attacks. — Petit Mai. — Fractional epileptic attacks 
present an endless variety, of which only a few of the common forms can 
be indicated. Almost any part of the full attack as previously described 
may alone constitute the limited seizure. Very frequently the disease 
presents an aura and the attack aborts. This may occur repeatedly, 
even for years, before the major seizures develop. Such warnings may 
occur in the intervals between the full attacks or after they cease, if the 
disease subside spontaneously or under treatment. A large number of 
cases present vertiginous attacks. The patient suddenly loses conscious- 
ness and falls, or nearly falls. There is usually slight twitching of the 
face, or perhaps only a little quivering about the eyes or mouth, or a 
deviation of the head and eyes, which may pass unperceived. Almost 
instantly the patient recovers himself, but may feel weak and faint. In 
other instances the patient falls heavily, but clonic movements and 
stertor do not develop. Again, the patient may fall, and become at once 
comatose and stertorous, as in apoplexy. 

Of great interest are the attacks marked mainly by a momentary loss 
or disturbance of consciousness. The face may suddenly pale and the 
eyes look vacant. Whatever is being done is interrupted, and imme- 

i " L'Encephale," 1908, No. 6. 



EPILEPSY. 647 

diately resumed. The patient ordinarily has no knowledge of anything 
unusual having occurred. In talking he suddenly stops, looks absent- 
minded, and takes up the sentence where it was broken. A musician 
may pause one or two bars, and continue. At table the cup is poised 
half way to the mouth, etc. In other instances a little twitching of the 
face is noticed, or the patient drops or throws whatever he has in his 
hand, and usually there is momentary rigidity during the brief uncon- 
sciousness. In some instances a few words are muttered, or a little 
saliva dribbles from the mouth, and in such attacks the escape of urine 
is far from infrequent. 

In rare instances the patient, under an irresistible impulse, rapidly 
walks or violently runs for a few moments in an automatic, unconscious 
way, and may fall finally in a fit, or may recover consciousness without 
an intervening convulsion ; or after a fit a patient may suddenly run for 
some distance (epilepsia procursiva). Attacks of stertorous or profound 
sleep have been recorded, into which the patient falls at intervals, and 
during which he can not be aroused. These may alternate with convul- 
sive attacks or may be replaced by them. Attacks of generalized or lo- 
calized trembling, local spasm, and salaam spasms may constitute the epi- 
leptic paroxysm. As before said, the only constant feature in epileptic 
attacks is a disturbance of consciousness during the period of the attack. 
Ceni l has observed sudden falling of body-temperature for about an 
hour, amounting to several degrees, sometimes recurring several times a 
day, and apparently constituting an epileptic equivalent. 

Psychic Equivalents of the Epileptic Attack. — Instead of 
epileptic attacks of the ordinary kind, or in alternation with such, or as 
a repeated prelude to the major convulsions, or immediately following 
the fits, w T e may have a variety of acute mental disturbances. Epilep- 
tics may unconsciously, automatically, and with apparent purpose per- 
form a number of coordinate acts. Homicidal, obscene, or pyromaniac 
acts may thus be done by epileptics, or intricate manceuvers, such as 
require the use of tools, may be accomplished. Subsequently, as a rule, 
they have no knowledge of such acts. The procursive fit may, in a sort 
of status, be prolonged so that the patient may make long flights, or, in 
a less violent way, make journeys of several hours' or several days' 
duration, during which the conduct is so natural as to attract no notice. 
Self-consciousness usually is rather abruptly restored, and they are 
astonished to find themselves at a distance from home, with an interven- 
ing blank period of time. Sudden wild, maniacal outbursts, in which 
the patient may be destructive and dangerous to others, are encountered, 
and these may terminate suddenly or be protracted for several days, 
attended by great excitement, a high pulse and temperature, and subse- 
quent collapse. Sometimes such attacks are stopped by a fit, or they 
may succeed a severe convulsion, or they may take the place of the 
convulsion. Epileptic automatism may, in a static form, last days 
and weeks, during which the patient conforms naturally to his sur- 
roundings, but subsequently has little or no knowledge of the automatic 
period. 

1 " Centralbl. f. Nervenh. u. Psychiat ," Oct., 1900. 



648 NEUROSES. 

Postparoxysmal Phenomena. — As physicians in practice rarely 
have the opportunity of seeing the patients in epileptic attacks, a 
knowledge of the postparoxysmal phenomena is important. As a 
result of the cortical exhaustion, a number of transitory symptoms 
follow the usual seizure. Tremor, paresis, disturbances of speech, of 
general sensibility, and of the special senses have sometimes been 
observed ; the muscular strength is commonly reduced, the knee-jerks 
are diminished or abolished, and muscular tone is lessened. Onuf, 1 
however, insists that during the convulsion and in the postepileptic 
period the reflexes are as commonly increased as diminished. Babinski's 
toe-sign is usually present on both sides during the period of stertor and 
in the comatose states that sometimes follow or substitute the attacks. 
Several attacks, repeated within a few hours, lead to an appreciable loss of 
body weight. The urine, even after a single attack, shows an increase 
of phosphates, particularly of the earthy phosphates, and of the nitrog- 
enous constituents. The temperature is commonly subnormal. This 
may occur even in petit mal and has been noted in the brain itself 
by Mirto. 2 The toxicity and acidity of the urine are increased, and 
Agostini 3 finds the gastric juice has toxic properties. These properties 
are most marked just before and after a fit, and are proportionate to the 
intensity of the attack. Vomiting after an attack is not uncommon 
and almost invariably causes the fit to be attributed to errors of diet, 
which is sometimes the case. Cabitto 4 claims that the sweat of epilep- 
tics is hypertoxic previous to the fits, and urges the use of hot baths 
in the treatment of the disease, asserting good results from their em- 
ployment. The special toxicity of the excretions in epilepsy is not 
proven. The arterial pressure is reduced, crises of polyuria, diarrhea, 
sweating, and salivation may be encountered. The presence of petechial 
ecchymoses, the bitten tongue, the voided urine, or fecal discharge is to 
be noted. Ordinarily, there is mental hebetude and sluggishness, a 
tendency to languor, and a desire to sleep. Headache is usually com- 
plained of, and often there is a feeling of extreme muscular fatigue and 
soreness. The psychic depression may reach a stuporous degree, and 
this may follow attacks that lack muscular violence. There is a decided 
tendency to mental deterioration, which, in the majority of cases, pre- 
senting frequently repeated major or minor attacks, markedly tends to 
dementia in the end. 

Myoclonus Epilepsy. — In rare instances myoclonia aud epilepsy 
occur in the same patient, constituting myoclonus epilepsy or the "asso- 
ciation disease." Such cases usually show marked degeneracy, and the 
disease begins early in life. Epilepsy usually antedates the myoclonic 
features which when once developed usually increase in severity and 
commonly eventuate in epileptic convulsions. 

The myoclonus of the association disease is somewhat atypical com- 
pared with the essential myoclonias. 5 The contractions are usually 
lightning-like, but may have a fibrillary character, involving certain 

i " Am. Med.," Jan. 30, 1904. 2 " Annali di Neurologia," 1899. 

3 " Kiv. di. Pat. Nerv. e Ment.," Hi, 1896. 4 " Kiv. Sper. di Freniat.," 1897. 

* Clark and Prout, " Am. Jour, of Insanity," Oct., 1902. 



'EPILEPSY. 649 

parts of muscles only, — a condition described as " live flesh," — and 
such manifestations are likely to develop into typical myoclonic con- 
tractions, though they may remain fibrillary through the life of the 
patient. A single general tonic contraction may rarely constitute the 
entire clinical picture. Myoclonus contractions end imperceptibly in 
the tonic stage of the epileptic paroxysm. The contractions are often 
strong and affect large masses of muscles, rendering locomotion difficult. 
The trunk is frequently affected, causing the body to jerk backward and 
forward and laterally. The face and distal portion of the extremities 
are frequently involved. Generally the myoclonus is symmetrical, but 
both sides are not always synchronously involved. Commonly it begins 
in the upper extremities, and in a few days or weeks involves the lower 
extremities, the body, neck, and face in the order given, the muscles 
about the eyes and mouth being the last affected. The tongue and 
diaphragm frequently suffer, in severe cases producing grunts and 
barks, a sort of laryngeal tic. As the malady develops the myoclonus 
becomes more and more persistent during the waking state, having a 
tendency to develop the myoclonic status, which may terminate in death. 
As a general rule, superficial and deep reflexes are increased, and also, 
as a rule, there is lack of physical and mental development. 

The prognosis as to recovery is extremely poor. Those who have 
reached mature years present extreme senility and progressive de- 
mentia. 

The diagnosis in a typical case is easy. There are family types 
and sporadic cases, the majority being of the latter variety. The con- 
dition may be acute and severe or mild and chronic. 

The treatment can be only palliative, but, as a general rule, long 
remissions both in the myoclonus and the epileptic course may be 
obtained by the use of bromids. 

Continuous Epilepsy. — Under the name of epilepsia partialis con- 
tinua, several Russian writers, notably Koshewnikow, have described 
a rare form of epilepsy, marked by characteristic major attacks, but also 
presenting in the intervals persistent clonic movements of limited extent. 
These clonic movements are sometimes of such vigor as to require the 
constant use of the unaffected hand to steady them. Their gradual in- 
crease in severity leads to a full attack. In some instances they have 
persisted during sleep. A somewhat similar fractional status is also at 
times observed in Jacksonian cases and in organic brain lesions. 

The General State. — The bodily health in epileptics may leave 
little room for complaint. Very commonly they present gastric dis- 
turbances, a sluggish skin, and constipated bowels; but usually this is 
due to the bromids with which these patients are so commonly satu- 
rated. Many epileptics have gormandizing habits and insatiate appe- 
tites for food. This, with the inactivity often forced upon them by the 
disease and reinforced by the bromids, leads to flabby fatness. As a 
rule, they are indifferent and careless, and often the finer mental attrib- 
utes and the keener sensibilities are dulled early in the disease. 

Diagnosis. — The diagnosis of epilepsy is often very difficult, if the 
attacks are incomplete or not open to intelligent observation. The 



650 



NEUROSES. 



disease in the nocturnal form, or in the varieties of petit mat with 
slight attacks, may not attract attention for years. When the suspicion 
of epilepsy is aroused, — as, for instance, by bed-wetting, bloody stains 
upon the pillow, unexplained bruises, conjunctival ecchymoses, a 
dislocation or fracture occurring during sleep, cuts on the face or 
scalp, a bitten tongue, or some automatic or convulsive attack, — a 
careful investigation will rarely fail to disclose the nature of the disorder. 
In such cases a history of repeated momentary unconsciousness, or of 
some of the various sensory aurse, is significant. An account of noc- 
turnal enuresis or nocturnal pavor in childhood is suggestive. Convul- 
sions during teething, the marks of degeneracy, or the presence of a 
family neuropathic trace have some weight. If there have been 
repeated convulsions, and they conform to the epileptic type, presenting 
sudden onset, with or without warning, tonic, clonic, and stertorous 
stages, and complete recovery, there is little room for doubt. 

We have, however, to exclude the epileptoid fits symptomatic 
of various functional and toxic conditions. Intestinal, renal, metallic, 
drug, and alcoholic poisonings may cause convulsions that very 
closely, or exactly, copy the attacks of epilepsy, and they may induce 
epilepsy in those predisposed. Vertigos of gastric, aural, ocular, and 
neurasthenic origin may suggest petit mal. Hysterical convulsions are 
often mistaken for those of epilepsy. Organic brain disease, such as 
tumors, cerebral palsies in children, and brain injuries, may occasion 
epileptiform attacks. Finally, epileptic seizures may be of the apo- 
plectic form and suggest cerebral hemorrhage, or the psychic equiva- 
lents may be confused with transitory mania. In every case it is 
obligatory to examine the patient rigorously from head to foot, both for 
the purposes of diagnosis and treatment. Of epilepsy, there is no one 
pathognomonic symptom. The following table shows some of the 
differential characters of epileptic and hysterical convulsions : 



Table of Differential Characters of Epileptic and Hysterical Attacks. 



The Fit. 


Epilepsy. 


Hysteria. 


Prodromes. 


Mental or physical premoni- 
tions. 


Emotional disturbance. 


Aura. 


Common, but momentary. 


Common and of considerable 
duration. 


Onset. 


Sudden, complete ; cry, fall, 
rigidity. 


Gradual. 


Consciousness. 


Instantly lost. 


Partially lost or retained. 


Course of convulsion. 


Tonic, clonic, and stertorous 
stages. 


Epileptoid and emotional 
phases. 


Duration. 


Two to five minutes. 


A few minutes to several hours. 


Positions. 


Governed by flexors, mainly. 


Tendency to extension, arc de 
cercle, opisthotonos, crucifixa- 
tion attitude, etc. 



EPILEPSY. 



651 



Table of Differential Characters of Epileptic and Hysterical Attacks 

( Continued ). 



The Fit. 


Epilepsy. 


Hysteria. 


Eyes. 


Pupils dilated and rigid. 


Pupils generally mobile and 
active. 


Tongue. 


Usually bitten. 


Bitten very exceptionally. 


Mouth. 


Frothing common. 


Frothing absent. 


Sphincters. 


Relaxed, usually. 


Usually continent. 


Pulse. 


Accelerated greatly and ten- 
sion increased. 


Rate and tension not much 
changed. 


Temperature. 


Elevated 1° or 2° F. 


Normal. 


Termination. 


In hebetude ; gradual. 


Rather prompt ending and little 
discomfort. 


Urine. 


Increased nitrogenous and 
phosphatic elements. 

Increased acidity and toxic- 
ity. 


Urea reduced, phosphates de- 
creased, and changed phos- 
phatic formula ; often large 
quantity, but of low specific 
gravity. 


Postparoxysmal con- 
ditions. 


Petechial ecchymoses, re- 
duced muscular strength, 
diminished knee-jerks, 
mental obscuration ; no 
memory of attack. 


No motor or reflex changes ; 
some recollection of phases of 
attack ; usual mental condi- 
tion at once regained ; pres- 
ence of various stigmata. 



Prognosis. — As an exception, but proving the rule of gravity in 
the prognosis of epilepsy, rare cases recover spontaneously. In a 
general way there is little hope for cure, if the disease, with repeated 
attacks, has lasted over two years, or been intense in its manifestations 
for even a shorter period. There is some tendency for it to appear, 
subside, reappear, or increase at the developmental epochs of dentition, 
puberty, adolescence, and the climacteric. Any inciting cause that is 
controllable is a favorable consideration. Epilepsy as a manifestation 
of degeneracy is of bad import. If there is any reason to suppose 
that organic cortical changes have occurred, or if dementia has appeared, 
the outlook is unfavorable. Grand mal cases offer a slightly better 
prognosis than petit mal or psychic cases. 

A single attack is almost never fatal of itself, but a condition of 
status is very likely to terminate fatally, and every attack undoubtedly 
leaves some harmful trace. Rarely a severe attack owing to some cardiac 
weakness terminates fatally through pulmonary edema. 1 The natural 
tendency of epilepsy is to dementia. The oftener the attacks occur, the 
worse the mental prospects. Death by status, or through vascular acci- 
dent, or by suffocation, or other physical mishap attending a fit, is not so 
very rare. Tuberculosis is a frequent cause of death. Epilepsy, with fits 
at long intervals, particularly if first appearing after twenty years of age, 
is not inconsistent with mental qualities of a high order, and may not 
shorten life or abridge usefulness. The majority of epileptics, under 
1 Shanahan, "N. Y. Med. Jour./' Jan. 11, 1908. 



652 XEUBOSES. 

proper conditions, may be advantageously and profitably employed in 
colonies provided for the purpose. 

Treatment. — A systematic study of the patient is the first step 
toward treatment. Every possible source of local irritation must be 
investigated. Occasionally, the aura may direct attention to some body- 
disturbance that acts as an inciting cause of the fits. Asthenopia due 
to errors of refraction, or faulty eye muscles, nasal disease, pharyngeal 
tumors, maxillary or dental faults, gastric inadequacy, intestinal para- 
sites, rectal ulcers, hemorrhoids and fissures, constipation, diarrhea, 
vesical and genital troubles, must all be sought and corrected, if found. 
Toxic conditions are equally important. Auto-intoxication from the 
stomach, intestines, or kidneys must be stopped. Alcohol, lead, tobacco, 
coffee, tea, and dietetic errors may incite the fits in those predisposed. 
Hygienic regulations are of the greatest importance. These pertain (1) 
to the diet, which should be nourishing, easily digested, and of reason- 
able amount. Milk, fish, vegetables, and suitable fruit, with a small 
amount of starchy articles and a very little meat, is generally best for 
epileptics. In some instances an absolute milk diet is decidedly helpful, 
and may be continued for many months with advantage. (2) Baths and 
exercise to keep the skin, muscles, and circulation active, and out-door 
life to further the same end, are valuable. Often vigorous manual labor 
is advisable. (3) The rooms, ventilation, clothing, occupation, amuse- 
ments, and habits of the patient are worthy of full consideration. Do 
not overlook the tendency to constipation. 

Improvement under such measures is the rule, and in rare instances 
it is one's good fortune to see epilepsy subside after the removal 
of some irritation or the correction of some toxic state. 

Turning to drugs, the most importance attaches to the bromids, but 
they should be reserved as a last resort or as an adjuvant. Cures by 
the bromid treatment are not to be expected. It is at best a palliative 
treatment and one often fraught with great disadvantage. Usually, in 
order to completely suppress the attacks an amount of bromid is re- 
quired that maintains constant hebetude. As a practical fact, if the 
fits are not controlled by sixty grains of bromid a day, the question is 
quite sure to arise whether the epilepsy or the bromid is the greater 
evil. It is a frequent experience to see patients, brutalized by bromid, 
go months without fits, but with a loss of mental and physical activity. 
Sometimes the attacks then recur with seemingly additional violence, or 
status may develop. Among the bromids there is little choice, but the 
sodium salt is least likely to disturb the stomach. During the use of 
the bromids the intestinal tract must be kept aseptic by the use of large 
quantities of drinking water or some of the laxative waters, and the 
administration of some antifermentative, like salol or betanaphtol. 
No attempt should be made to displace nocturnal fits by giving large 
doses of bromid at bed-time. Kather should the nocturnal feature of 
the disease be favored, and in other cases it is to the advantage and 
safety of the patient to induce a nocturnal incidence of the attacks. To 
this end the bromid may best be administered in a single dose on rising 
in the morning, or by a dose after breakfast and at noon. When men- 



MIGRAINE. 653 

struation aggravates the epilepsy, the closes of bromid may be doubled 
for a few days before, during, and after the period. 

Sometimes the use of antipyrin, phenacetin, trional, or other of the 
coal-tar derivatives, with bromids, gives better results than the bromids 
alone. Digitalis or belladonna in similar association will be found 
valuable in those cases where there is weak circulation. Sumbul and 
solanum have their advocates, but so has had every other remedy ever 
known to man. Flechsig has proposed the use of opium, to be followed 
by bromids, in cases of long standing. He gives opium in doses gradu- 
ally increasing from one to fifteen grains or more a day, if well borne, 
and after a few weeks abruptly stops the opium, substituting bromid, 
twenty to forty grains, three times daily. Bechterew combines bromid, 
adonis vernalis, and codein with favorable results. Any one of these 
plans may be tried when bromid alone fails or loses its force. Richet 
and Toulouse x called prominent attention to the asserted value of with- 
drawing common salt from the food of epileptics, thereby securing, it 
was thought, a better absorption of the bromids. A very general trial 
of this measure has led to the belief that it is one of decided value, and 
as a rule smaller closes of bromids are more efficacious under this 
regime than larger ones without it. Even alone, without the use of 
bromid, the withdrawal of salt secured a reduction of the number of fits 
in fourteen cases reported by Garbini, and the attacks were less severe. 
The plan is entitled to a trial in all cases, but is often very difficult to 
carry out in the usual run of private practice. The physical health de- 
clines rather rapidly if salt be entirely excluded, but a decided limitation of 
the amount of salt can usually be effected with advantage. Patients vary 
greatly in this regard as in all others, and personal peculiarities and re- 
quirements must be kept in view. 



CHAPTER X. 
MIGRAINE, 



Migraine is an explosive, paroxysmal psychoneurosis. The 
attack, usually commencing with sensory and mental symptoms, is 
almost always attended by headache, which is frequently one-sided, 
and there is generally nausea and vomiting. It is sometimes called 
hemicrania, sick headache, or megrim. Owing to the vomiting, it is often 
erroneously attributed to " biliousness." 

Etiology. — Heredity is strongly marked. It is more commonly 
direct than in almost any other neurosis. Migraine may sometimes 
be traced through several generations, numbering dozens of cases in 
a single family tree. Any neuropathic family is almost sure to pre- 
sent cases of migraine. It seems capable of transmission by transfor- 
mation, alternating with hysteria, epilepsy, and insanity. It may be 
associated with the graver neuroses, or with psychoses, in a given 
patient. Gout and arthritism have similar close relations with it. 
1 Kichet and Toulouse, Paris Academy of Sciences, Nov., 1899. 



654 NEUROSES. 

Thirty per cent, of cases begin between five and ten years of age, and 
the balance appear mainly at puberty, adolescence, and during early 
adult years. In rare instances it may begin after thirty. The female 
sex is somewhat more commonly aifected than the male. 

The inciting cause is often obscure. Some cases date from periods 
of lowered physical health arising from any cause. The cases beginning 
in early childhood very frequently folloAV the first systematic use of the 
eyes for near vision, as in school- work. Eye-strain, arising from accom- 
modative or muscular asthenopia, is certainly competent to incite 
migrainous attacks in those predisposed. Gouty or lithemic conditions, 
constipation, indigestion, fatigue, lactation, emotional disturbance, or any 
febrile movement may set up the attack. 

Symptoms. — The symptoms of migraine are those of the attacks. 
These vary considerably in different patients, but are tolerably uniform 
for the given case. There are usually : (1) Premonitory symptoms ; 
(2) sensory disturbances ; (3) headache ; (4) nausea ; (5) vomiting ; (6) 
sleep ; and (7) complete recovery, occurring generally in the order 
given. In addition, there are usually vasomotor symptoms and occa- 
sionally mental and motor phenomena. 

The premonitory symptoms are most common in the cases in which 
the early sensory symptoms are least marked. For a few hours or a 
day the patient feels heavy, dull, apathetic, and is usually indifferent 
and irritable. There may be slight headache or somnolence. After a 
nap he may wake up with a fully developed one-sided headache, or this 
may be present on awakening in the morning. The sensory symptoms 
occur in over half of the cases. They usually begin quite suddenly. 
Bright spots before the eyes, colored rings, luminous zigzags, hemi- 
anopsia, dimness of vision, clouds, etc., are some of the subjective visual 
disturbances. They affect both eyes, and are sometimes lessened if the 
eyes are closed. They are usually most pronounced or entirely confined 
to the homologous half fields. Some patients only feel a vague ocular 
discomfort, or decided photophobia may be present. Taste and hearing 
are exceptionally affected in a similar manner. In some cases there are 
sensory symptoms in the limbs, face, throat, or tongue, but especially in 
the hand or foot. A tingling or numbness invades the parts and gradu- 
ally advances toward the center. These sensory disturbances usually 
last ten to twenty minutes and then subside, the headache immediately 
displacing them. 

Motor symptoms, though exceptional, are very valuable indica- 
tions of the cerebral nature of this neurosis. The extremity which 
presents tingling may show paresis, and the following headache is 
usually on the opposite side. Motor aphasia may be added to right-arm 
tingling and left hemicrania, and the left halves of the retina may be 
disturbed by visual sensations, which are referred outwardly to the right 
fields. Temporary word-deafness has also been recorded. In another 
group of rare cases there is transient unilateral paresis of the oculo- 
motor, marked by ptosis, outward squint, double vision, pupillary dila- 
tation, and loss of accommodation, constituting the so-called ophthalmo- 
plegic migraine. 



MIGRAINE. 655 

Slight mental changes occur in some patients, such as depression, 
mental confusion, restlessness, loss of memory, stupor, double conscious- 
ness, or a recurrence of some vivid memory. Attacks of temporary 
delirium, with or without subsequent ignorance of the mental state, are 
sometimes seen. 

The headache is the most uniform, dominant, and distressing symp- 
tom. It varies in different cases in degree, duration, and location, but 
is commonly intense and ordinarily circumscribed, at least at first. 
Often commencing as a localized, intense pain in a small spot in the 
temporal, frontal, ocular, or occipital region, it gradually spreads to the 
rest of the same side of the head, or may become diffused all over the 
head. Less commonly it commences on both sides as a frontal or 
occipital pain. Rarely, it passes down the back of the neck and into 
the arm. The character of the headache is tolerably uniform in the 
same case, but some patients have several varieties, which reappear from 
time to time, and are recognized as old acquaintances. The character of 
the attack may also undergo great modifications during the patient's life- 
time. The headache lasts from one or two hours to ten, twenty, or forty, 
and may subside abruptly after nausea or nausea and vomiting, or grad- 
ually grow less and disappear. During the height of the headache the 
patients usually shun light and noise, and remain as quietly recumbent as 
possible. Movement, such as rising or stooping, intensifies the pain. 
Tenderness of the scalp or nerve-trunks is unusual. 

In most cases nausea appears after the headache develops or has 
reached its height, and there is complete anorexia. Digestion appears 
to be stopped, as unchanged food is sometimes vomited many hours after 
its ingestion. 

The nausea leads to vomiting in a fair proportion of the cases, and 
emesis is attended by much retching and difficulty. It is often repeated 
and protracted, so that biliary matter may finally appear in the ejecta. 
Usually, once commenced, it is provoked by swallowing any fluid, or 
even by the saliva, which is commonly apparently increased in amount. 
Often the patient is cold, pinched, clammy, and suggests the collapse of 
seasickness or choleraic disturbance. Frequently, as the vomiting 
subsides, a feeling of great relief is experienced, the headache ceases, 
and the patient falls into a quiet sleep of a few minutes or several hours, 
from which he arouses and asks for, or tolerates, a little food. 

The vasomotor symptoms are interesting, and have attracted great 
attention. Early in the attack, before the headache has appeared, there 
is frequently pallor or mottling of the face. In some instances a vivid 
red streak in the middle of the brow or a one-sided flush invariably 
appears. The pallor is succeeded by flushing, in some, and there may 
be general profuse perspiration. Commonly, the extremities are cold 
during the severe pain, the pulse sharp and retarded. Usually the 
contracted pupils show the participation of the cervical sympathetic. 
This rarely is unilateral, and may produce retraction of the eyeball. 
The inhibited digestion may be due to a similar angiospastic condition 
of the gastric arterioles. As the attack declines, the surface reddens, 
the pulse resumes its proper rate, the pupils relax, the pallor disappears, 



656 NEUROSES. 

and in rare cases some puffiness in the scalp has been noted. Increased 
diuresis may follow. In the intervals the patient may feel perfectly 
well. 

Course. — Migraine has a tendency to persist for many years, when 
once established. Commonly, in women, after the menopause, it sub- 
sides, and it disappears in men after fifty-five or sixty. The attacks 
occur with more or less regularity, and sometimes with remarkable 
periodicity. Menstruation may provoke it monthty in women. It 
sometimes occurs every Sunday, especially in men who change their 
daily routine at that time. Irregular intervals of weeks or months 
may intervene, when any of the inciting causes may precipitate it ; but 
it is usually noticeable that an inciting cause or condition, acting soon 
after an attack, fails to induce an immediate recurrence. It is 
evident that the attack has cleared the atmosphere and exhausted the 
susceptibility. In certain rare instances the migrainous attacks have 
been replaced by epileptic seizures presenting the same premonitory 
features. A case has been seen presenting migraine, epilepsy, and 
transitory mania, apparently as alternating equivalents. Krafft-Ebing x 
reports a number of cases in which transitory mental disorder occurred 
as part of, or in alternation with, migraine. The premonitory hemiopia 
in a case reported by Noyes became permanent. In advanced years the 
migraine may apparently be replaced by labyrinthine vertigo. After 
many attacks, some intellectual impairment has been noted. Granting 
the neuropathic substratum in migraine, the association or succession of 
other neuroses and psychoses is surprising mainly by its rarity. 

Pathology. — In the absence of knowledge regarding the morbid 
anatomy of migraine, we are thrown back upon theories and analogies. 
Attracted by the vasomotor symptoms, many attributed the migrainous 
attacks to disturbance of the sympathetic. This is a clear confusion of 
effect and cause, of symptom and disease. Taking into consideration 
the cortical features manifest in sensory disturbance, hemiopia, tingling, 
aphasia, motor loss, crossed hemicrania, mental features, cardiac and 
digestive inhibition, and the vasomotor disturbance itself, there can be 
little doubt that migraine is a cerebral disorder. Its resemblance to 
epilepsy, if not its actual relationship, 2 points to the same conclusion. 
The exact nature of the cortical instability is for the future to reveal. 

Diagnosis. — The diagnosis of migraine depends mainly upon its 
paroxysmal and recurrent character and its definite clinical features. 
The sensory premonitions and vasomotor phenomena are very significant 
when present. In cases presenting migrainous attacks of the milder 
sorts, it is difficult to be sure that the headache is not due to some ordi- 
nary cause, until its repeated recurrence under somewhat similar circum- 
stances declares its nature. " Sick headache " is almost invariably 
migraine. The vesperal headaches of syphilis, and the quotidian or 
tertian headaches of malaria, occur with greater periodical regularity 
and with much shorter intervals than the attacks of migraine. Both lack 
the nausea, vasomotor symptoms, and complete recovery. From petit 

1 "Alienist and Neurologist," Jan., 1900. 

2 Wilfred Harris, "Transient Hemibpias," "Brain," 1897. 



MIGRAINE. 657 

mal the diagnosis may often offer considerable difficulty. The pre- 
monitory sensations may be taken for an aura, but their prolonged dura- 
tion is unlike the momentary warning of epilepsy. Unconsciousness 
does not occur in migraine ; it is the most constant feature of epilepsy. 
Headache, as a symptom of other disease developing in a migrainous 
patient, may be overlooked and the concurrent malady neglected. The 
headaches of Bright' s disease, of cerebral tumor, of syphilis, or malaria 
may be wrongly attributed to the neurosis. Sensory, aphasic, and paretic 
features sometimes suggest Jacksonian attacks and focal brain dis- 
ease. A careful study of the case and the absence of other evidence 
of organic lesion will usually suffice. 

Prognosis. — Migraine is usually a stubborn and persistent malady. 
It has a tendency to last until involutional changes in the organism 
commence, when it frequently spontaneously subsides by a gradual in- 
crease of the intervals between the attacks, rather than by a lessening 
of their severity. If the disease is of short duration, and some remov- 
able cause can be discovered, the prognosis is fairly good. In older 
cases the attacks can usually be rendered less frequent and often aborted 
if the patient is watchful and persists in treatment. 

Treatment. — Unless the condition or agent provocative of the 
attacks can be discovered and removed, there is little likelihood of fully 
successful management. To this end all sources of peripheral irritation 
and auto-intoxication must be carefully investigated. Eye-strain, im- 
proper diet, excesses, or bad habits of any sort must be corrected. In 
some migrainous patients any relative excess of nitrogenous food is sure 
to induce an attack. As a rule, for these patients an abundance of out- 
door air, free cutaneous and intestinal excretion, and an unstimulating 
diet are indicated. A tablet of T ^- of a grain of nitroglycerin, allowed 
to dissolve in the mouth, and taken at the earliest premonition, will 
sometimes abort an attack. Caffein has a similar effect with some 
patients. Others, by taking a large dose of bromid and lying down, 
occasionally escape. Others, again, by inducing emesis, or by washing 
out the stomach, interrupt the paroxysm. When the attack is once on, 
heat or cold to the head, warmth to the extremities, and a mild sinapism 
over the stamach are helpful. A dark, quiet room is usually demanded. 
Morphin will control the pain, but should, if possible, be avoided, to 
prevent setting up the opium-habit. 

If the attacks are of considerable frequency, — say one or two a week, — 
a continuous course of bromid, as in epilepsy, may give good results. 
In the forms marked by paretic symptoms of onset — by ophthalmoplegia, 
for instance — the bromid treatment is of the greatest value, and such 
cases should be managed much as cases of epilepsy with incomplete 
attacks. Cannabis indica in association with the bromids or alone 
sometimes is of real value. A reliable fluid extract may be used. Be- 
ginning with 2 drops after every meal, the dose may be increased 1 
drop daily until 15 or 20 drops are taken three times a day, and then 
reduced in the same way, and the course repeated after an interval 
of a week. 

42 



658 NEUROSES. 

CHAPTER XI. 
NEUROSES FOLLOWING TRAUMATISM. 

The subject of neuroses following injuries is one of vast importance 
to the general practitioner, and has a medicolegal side of much interest. 
The question has been greatly befogged for many reasons. The first 
important work directing attention to this class of cases was the publi- 
cation of Erichsen in 1871 on "Spinal Concussion," reprinted in 1875. 
In it he reports fifty- three cases resulting from injuries, received mainly 
upon railways. These cases present all manner of lesions, alone hav- 
ing in common the negative feature — absence of external evidence of 
injury. In this list are embraced cases of fracture of the dorsal ver- 
tebra?, hemorrhage into the cord, division of the cord, meningitis, simple 
nervousness, hysteria, neurasthenia, and pretty much everything else. 
Unfortunately, " concussion of the spine," as set forth by Erichsen, 
was seized upon by lawyers as the basis for prosecuting suits for damage 
against corporations, and it became fixed as a disease-entity in the legal 
and medical mind. In 1883 Page, a railway surgeon, brought out a 
book written from an ex parte standpoint to counteract the contentions of 
Erichsen, and the battle raged fiercely from both sides for a number of 
years. Subsequently, in Germany, Oppenheim, in 1889, made a closer 
classification between organic injuries and those not marked by gross 
histological changes, and proposed the term " traumatic neuroses " for 
the latter. About the same time, and subsequently, Charcot taught and 
demonstrated that the nervous symptoms in these cases, apart from those 
attributable to organic lesions, were precisely the same as are presented 
in neurasthenia and hysteria. 

The early errors of Page and Erichsen are easily understood if it is 
recollected that the finer anatomy of the nervous system, as well as the 
physiology of the cord, was but little known in their time ; that the 
electrical reactions of nerves and muscles were not clearly understood ; 
that the stigmata of hysteria and the symptom-group of neurasthenia 
were still undeciphered. Unfortunately, there was a tendency to dignify 
all the morbid conditions following serious injury by such terms as 
" spinal concussion," " railway spine," " traumatic neurosis," and 
" Erichsen' s disease," without any attempt to distinguish their real 
significance or differentiate among them. 

It must be evident that after a railway injury, as after injuries 
occurring under any other circumstances, three classes of conditions may 
arise: (1) All sorts of injuries of a surgical character; (2) traumatic 
hysteria ; and (3) traumatic neurasthenia. Various combinations of 
these three may result, and they are commonly found in association. 
Surgical conditions and neurasthenia or hysteroneurasthenia may be 
present, or neurasthenia or hysteria may alone follow concussions, in- 
juries, or frights attending accidents, especially upon the railways. It 
should be clearly recognized that the nervous disturbances marking 
neurasthenia and hysteria are likely to develop in proportion to the 
predisposing tendency in the individual, and also in proportion to the 
amount of mental shock attending the accident. In railway accidents 



NEUROSES FOLLOWING TRAUMATISM. 659 

the element of fright reaches its highest development, and consequently 
there is a preponderance of neurasthenia and hysteria, or their combi- 
nations, in persons the victims of such accidents. 

In the consideration of a case in which physical conditions and 
nervous symptoms have originated from injury, it is necessary to look at 
it first as a surgical case, and secondly to consider it as a nervous case. 
Cranial fracture, cerebral hemorrhage, focal epilepsy, or traumatic 
insanity may follow injuries to the head. Dislocations and fractures of 
the spine, lacerations and hemorrhages of the cord, myelitis and menin- 
gitis, muscular strains, and ligamentous ruptures may follow blows and 
injuries to the back, either directly or indirectly applied. Concussion, 
if sufficiently severe, even without apparent local physical injury, may 
induce hemorrhages in the meninges or in the cerebrospinal apparatus. 
It would be well to drop the terms concussion of the brain and spinal con- 
cussion, as there is a tendency to look upon them as vague but actual 
diseases. Concussion is a mode of action only, and like any other mani- 
festation of force may vary in every degree so as to be entirely insignifi- 
cant or of the utmost gravity. Accidents producing such injuries may at 
the same time so disturb the nervous equilibrium that neurasthenia is de- 
veloped or hysteria is provoked. The neurasthenia of traumatism, or of 
fright associated with the possibilities of traumatism, is exactly the same 
as neurasthenia arising from any other source. Hysteria associated with 
traumatism, or conditions associated with traumatism, is exactly the same 
as hysteria occurring from other causes. The combinations of organic 
with nervous diseases of a character not yet associated with known organic 
changes must be deciphered on distinct lines. The surgical features 
have their own prognosis ; the nervous disorders have their proper out- 
look, and they are not necessarily related. 

Cases of this character may be considerably complicated by litigation. 
In exceptional instances there is dishonest and outright simulation. 
More frequently the anticipation of legal proceedings, the numerous 
special examinations, the suggestions arising from attorneys and phy- 
sicians, and the very natural tendency to exaggeration serve to highly 
accentuate the subjective side of the clinical picture. Corporations and 
their legal and medical officers usually look upon all such claimants as 
dishonest, and by their bearing, if not by their words, antagonize and 
aggravate the patients who come to take an almost morbid, spiteful 
pleasure in cultivating their aches and bodily and mental distress. 
They see damages in every symptom, and the hopeful expectation of 
physical recovery that is so potent for good is completely destroyed. 
This peculiar, morose, depressed, and querulous mental attitude has even 
been dignified by the names litigation psychosis and traumatic psychosis. 
It not infrequently results that, upon the completion of litigation and 
the cessation of irritation and introspection, prompt improvement takes 
place. From a medical standpoint, it is always better that an immediate 
legal settlement be made. 

The profession should recognize that traumatic neurasthenia and 
traumatic hysteria are serious and disabling conditions. Every case 
must be specialized, and the amount of disability and the probability of 
its duration must be estimated from all the facts. 



PART VIII. 

SYMPTOMATIC DISORDERS. 



There are a number of symptomatic disorders very commonly met 
with in nervous maladies and essentially nervous in character that 
nearly reach the dignity of diseases. Headache, vertigo, insomnia, and 
neuralgia are the most important. Headache and vertigo have been 
specifically emphasized whenever they had a special relation to diseases 
of the nervous apparatus, and can be easily followed from the index. 
Neuralgia and sleep disorders require further study. 



CHAPTER I. 

NEURALGIA. 

Neuralgia (nerve pain) is always a symptom. Difficulty arises 
from the fact that intense neuralgic affections have often been confused 
with their most prominent painful symptoms. Neuritis and neuralgia 
have been differentiated only in recent years. Even now there are many 
who fail to discriminate between trifacial, brachial, and sciatic neuri- 
tides, and neuralgias of similar location. It also appears proven that 
an irritation at first producing neuralgia may, by its persistence, set up a 
neuritis or contrariwise, and it is certainly clear that neuralgia is one of the 
symptoms of neuritis. Gordon, 1 basing his conclusions upon the histolog- 
ical examination of nerves removed in eight cases of facial neuralgia, 
says: 

(1) The occurrence of degeneration of the peripheral nerve is fre- 
quent if not constant in neuralgia. 

(2) That this nerve degeneration is very probably a primary condition, 
which as a neuritis assumes an ascending course and involves secondarily 
the Gasserian ganglion. Although this contention is still debatable, there 
is great probability in favor of the above view. 

1 "N. Y. Med. Jour.." July 21, 1906. 
660 



NEURALGIA. 661 

(3) The blood-vessels undoubtedly play a certain role in the causation 
of a degenerative state of the peripheral nerve. 

(4) That it is difficult if not impossible to draw a sharp distinction 
between neuritis and neuralgia, as accumulated facts show an anatomical 
basis in the latter affection. 

(5) In view of these anatomical facts, it is highly important to re- 
move surgically a nerve affected with so-called neuralgia as early as pos- 
sible after a short trial of medical treatment is given. 

The distinction, therefore, is not always easy. Neuralgia may be an 
expression of disturbance acting (1) locally, or (2) systemically, or (3) 
in both ways at once. Neuralgias may be visceral or peripheral, and many 
visceral diseases have their corresponding peripheral or somatic neuralgias. 
In this relation the reader is referred to the section on Pain and the Re- 
ferred Pains of Visceral Disorders as outlined by Head (p. 57 et seq.). 
Many neuralgias — such as angina pectoris in cardiac disease, intercostal 
neuralgia in gastrohepatic disease, testicular neuralgia in kidney disease, 
pleurodynia, gastrodynia, and coccygodynia — are very clearly symptom- 
atic and secondary. There are certain conditions favoring the appearance 
of neuralgia, and there are a few localized neuralgias that require indi- 
vidual consideration. 

Conditions Favoring Neuralgias. — Intense neuralgic conditions 
are rare in early life and in old age, but when they appear after sixty, 
they usually have an irremediable organic basis and are correspondingly 
intractable. Women suffer in this way more than men. In some 
instances there is a marked hereditary tendency, and, as a rule, the 
"nervous" and neurotic, the possessors of unstable nerve-cells, are 
most prone to neuralgic conditions. This shows out strongly in the 
clinical histories of hysteria and neurasthenia. Arthritism in its broad- 
est sense is a congener. 

The inciting causes of disturbance marked by neuralgic features are 
very numerous. Any impairment of health, any debilitating influence, 
any continuous fatigue, anemia, emotion, concussion, may be symptom- 
atized by neuralgia. Exposure to cold, peripheral local irritations, and 
any cause of neuritis, as well as every form of neuritis, may set up 
neuralgic pains. Nearly all toxic influences may induce neuralgia. 
Those toxic causes which are so active in the etiology of neuritis may 
induce neuralgic pain. Lead, alcohol, diabetes, auto-intoxication, mala- 
ria, and acute infections may all have neuralgic symptoms. The root 
pain of tabes, the peripheral pains of cortical brain disease, and the 
nerve pains of neuromata are easily understood. 

Characters of Neuralgic Pains. — Neuralgic pains are commonly 
unilateral, and confined to the distribution of a part or the whole of a 
single nerve, or of several nerves. The pain is inconstant and usu- 
ally paroxysmal, with complete freedom in the intervals, or with a dull 
ache between the severe pains. They are usually described as dart- 
ing, stabbing, tearing, ripping, lightning-like, as if shot, and by other 
words or phrases expressing their sudden, instantaneous character. 
They may be repeated rapidly during a few minutes, or occur singly 
at longer intervals. The pain is located deeply in the parts, but often 



662 SY3IPT03IATIC DISORDERS. 

is attended by great superficial hypersensitiveness. At the same time 
deep pressure may give relief. During the painful attacks, motion of 
the muscles of the parts, a touch, even a breath of air in severe cases, 
may renew the stabbing pains. Heat, cold, and alcoholics may intensify 
or diminish the pain in various cases. 

Neuralgic areas during the pains and between the paroxysms 
usually present nerve tenderness. This is most prominent at certain 
points where the nerve is superficial, overlies bone, or is inclosed by 
fascia or other rigid tissue. They correspond to the " maxima " of 
Head and constitute the " tender points " of Valleix. 

In some cases the pain has a tendency to radiate into other branches 
of the same nerve or into related nerves. In the same way irritation of 
one branch of a nerve, especially of the trifacial, may induce neuralgia 
in another division. Neuralgic pains are often very fugaceous, appear- 
ing now here, now there, especially when arising from systemic causes. 

The associated muscles may act spasmodically in the pain storms. 
This is rather common in the trifacial form, but it is difficult to tell 
whether the grimace is volitional or not. In the same way a sharp 
leg neuralgia may be attended by a drawing up of the limb, and, if the 
patient is walking, he may suddenly fall. 

Very often the parts subject to neuralgia show vasomotor disturb- 
ance and trophic changes. The vessels, at first constricted, usually 
dilate, and flushing follows. Edema, local sweating, erythema, scali- 
ness, loss of hair, blanching of the hair, herpes, and pigmentation may 
attend upon neuralgia that is symptomatic of a neuritis. Localized 
hypertrophy, due to the continued congestive features of neuralgia, may 
be encountered. 

Pathology. — The mechanism of neuralgic pains has been a fruitful 
theme of discussions, into which we need not enter. The following 
facts indicate the interposition of the spinal apparatus in neuralgic 
pains : (1) The pain may occupy the areas related to several spinal 
segments, and not closely follow the distribution of nerves. In shingles, 
for instance, the herpetic and painful area on the upper trunk is bounded 
by horizontal planes, and not by the intercostal furrows ; (2) irritation 
of one branch of the nerve may be radiated into another, which it could 
only reach by way of the nuclear cells ; (3) the pain may develop exclu- 
sively in another region than the one irritated : (4) division of the poste- 
rior nerve-root, as has been done, especially by Abbe* and others, or 
separation of the afferent path anywhere between the cord and lesion, 
immediately stops the neuralgia ; (5) irritation of the proximal stumps 
of a divided nerve gives rise to pain referred to the periphery to which 
that nerve is anatomically related. This is seen in amputation neuro- 
mata and in anesthesia dolorosa. 

By this conception we are able to understand how systemic poison- 
ing, as by alcohol or malaria, may so predispose the spinal ganglia that 
pain is occasioned by a peripheral disturbance, perhaps insignificant in 
itself. It also explains the ability of an intense or protracted peripheral 
irritation to set up localized pain, which may long persist after the irri- 
tant condition has subsided. 



NEURALGIA. 663 

Varieties of Neuralgic Pains.— An enumeration of the common 
varieties of neuralgic pains is all that need be attempted. They are 
classified (1) as to location, and (2) as to cause. 

Varieties Depending upon Location. — Trifacial, cervico-occipital, eer- 
vicobrachial, brachial, dorso-intercostal, intercostal, lnmbo-abdominal, 
spinal, sacral, coccygeal, sciatic, crural, metatarsalgia, etc. Visceral 
forms : Pleurodynia, angina pectoris, cardialgia, gastralgia, gastrodynia, 
hepatalgia, enteralgia, nephralgia, ovaralgia, testicular neuralgia, etc. 

Varieties Depending on Cause or Association. — Epileptiform neu- 
ralgia, really a neuralgic facial tic ; reflex sympathetic neuralgia, one in 
which the pain appears at a distance from its irritant source ; traumatic 
neuralgias, really traumatic neuritis ; occupation neuralgias, a part of 
occupation or fatigue neuroses ; herpetic neuralgias, the neuralgic pains 
attending zoster ; hysterical neuralgias, really stigmata of the neurosis ; 
rheumatic, gouty, diabetic, anemic, and malarial neuralgias, associated 
with, and often due to, the respective systemic states ; syphilitic neu- 
ralgia, very rare, and due to the syphilitic cachexia. Pains in syphilis 
are ordinarily due to neoplastic infiltration of the nerves and other tis- 
sues ; degeneration neuralgia appears in the aged, and is due to involu- 
tional changes in the organism. 

Trifacial Neuralgia. — Of all varieties of neuralgia, that occurring 
in the trifacial is the most important. It often is extremely persistent 
and intractable. The constant exposure of the fifth pair in the face and 
nasopharynx to injury and infection of the periphery, the course trav- 
ersed by the nerve through bony channels and over resisting struc- 
tures, and its very extensive distribution territory, lay it especially liable 
to irritatino; and traumatic conditions. Its association with other cranial 
nerves sometimes causes it to be reflexly affected, as from the motor 
oculi and pneumogastric. It is aifected about equally often on either 
side, and very rarely bilaterally. Exceptionally, all three branches are 
painful, but more commonly the neuralgia is confined to one or two of 
them. 

When the first branch is affected, the pain is supraorbital, radiating 
from the supraorbital foramen over the corresponding side of the brow, 
or even to the vertex. The eyeball is frequently tender, or may be the 
seat of neuralgic pains. Tender jwints are usually found at the notch, 
on the upper lid, and over the lower margin of the nasal bone. When 
the second division is aifected, the pain is located over the cheek, between 
the orbit and the mouth, spreading onto the wing of the nose. The 
tender points are at the lower border of the nasal bone, over the malar 
prominence, at the infraorbital foramen, on the gum above the canine 
tooth, and sometimes on the hard palate. In neuralgia of the third 
division, pain traverses the lower jaw and tongue and the corresponding 
portion of the face, extending, by the auricular branches, to the zygo- 
matic, and even to the parietal region. The tender points are over the 
inferior dental foramen, in the temple, and in the parietal regions. 

The pain is usually intense, lancinating, shock-like, and may cause 
the most excruciating torture. The attacks, if at all severe, usually 
cause vasomotor and secretory disturbance. Lacrimation, salivation, 
and mucous discharge from the nose may be encountered. The brow, or 



664 SYMPTOMATIC DISORDERS. 

lip, or tongue,, or the entire side of the face, may be swollen and edem- 
atous. The hyperalgesia is often intense, so that wiping the nose or 
eye, taking liquids into the mouth, and mastication are attended by 
great suffering, and often provoke a repetition of the neuralgic pains. 
Herpes possibly only occurs when histological changes in the nerve or 
its nucleus have taken place. 

The neuralgias of the brachial, intercostal, and sciatic nerves are 
often intense, and present similar tender points and superficial hyper- 
algesia. The location of both have been described on page 57 et seq. 

Treatment. — The treatment of a symptom is necessarily the treat- 
ment of the underlying disease. Local and constitutional conditions 
capable of determining neuralgic pains must be carefully sought, and 
local conditions capable of producing neuralgia at a distance must not 
be overlooked. In order to specialize the matter we may consider the 
treatment of trifacial neuralgia in detail. With proper variations the 
same considerations and measures apply to other neuralgias. 

Treatment of Trifacial Neuralgia. — In the treatment of a tri- 
facial neuralgia a careful search for local irritation is first to be made. 
In many cases pressure upon a given point will check or inhibit the 
pain. If such an inhibiting point can be found, it is a source of great 
relief to the patient. If the pain is intense and the hyperalgesia severe, 
the use of morphin or cocain may be required to make the examination. 
This should commence at the vertex. The scalp and brow should be 
carefully palpated, the orbit investigated, the eye examined for refractive 
errors, local inflammation, and glaucoma. The nasal fossa?, the antra, 
the nasopharynx, the mouth, and especially the jaws, must be thoroughly 
scrutinized. It is useless to sacrifice teeth unless a competent dentist 
finds them diseased. As a rule, a careful dental overhauling is a nec- 
essary measure in protracted cases, even where the pain is not located 
in the dental branches. 

The general systemic state is of equal importance. The facial neu- 
ralgias of infections, grip, malaria, and eye-strain commonly involve 
the ophthalmic division. Dental and maxillary disease is most common 
in the middle branch. Compression of the nerve in the dental canal 
often causes neuralgia of the third branch. In elderly people who have 
lost their teeth the resulting greater elevation of the chin stretches the 
dental branch of the third, and may cause a neuralgia that can be 
readily relieved by the use of dental plates of proper vertical propor- 
tions to prevent the tug upon the affected nerve. Anemias, cachectic 
states, and conditions of auto-intoxication from the kidneys, stomach, 
or intestines, must be corrected. Neoplasms in the cranial cavity, or 
facial fossae, jaws, and antra, may impinge upon the nerve and set up 
neuralgic pains. 

In the management of these cases it is usually necessary to maintain 
complete rest. Many cases, otherwise rebellious, improve very rapidly 
under the Mitchell rest system. Food must usually be taken in a liquid 
form, and in very severe cases the nasal tube must be employed. Masti- 
cation ordinarily provokes the pains. Directed against the pain we have 
in malarial cases to employ large doses of quinin, or Warburg's tine- 



NEURALGIA. 665 

ture, or both, for several days, and follow them with arsenic, iron, and 
quinin in moderate doses for weeks. The purpose is to cinehonize the 
patient and maintain a saturation of the blood with quinin. A prepara- 
tory calomel purge is of importance. In other cases we have to resort 
to sedatives, and are usually reduced finally to the use of morphin. The 
reliable aconitia of Duquesnel, in doses of ■^-J-g- of a grain, several times 
a day, is sometimes of great service, and may be increased if well borne. 
Slight numbness of the lips, tongue, and fingers may be expected, and 
this amount of action can not safely be exceeded. Cocain, by local 
hypodermatic administration or anodal diffusion, is not reliable, and often 
acts badly. Morphin should only be given by the physician or a com- 
petent nurse. It is well if the patient can be kept in ignorance of the 
nature of the drug, owing to the tendency which is especially strong 
in these neurotic cases to the acquirement of the opium-habit. The 
use of electricity is more often disappointing than otherwise. The posi- 
tive pole to the tender area, with three to ten milliamperes uninterrupted 
current for ten minutes, sometimes allays the pain. The current should 
commence from zero, slowly increase until felt as " warm," and finally 
decrease in the same way, without shock. The use of strychnin hypo- 
dermatically in large, repeated, and increasing doses, the patient being 
meanwhile confined to bed and carefully fed, as advocated by Dana, is 
a promising line of treatment. Commencing with -gL- of a grain every 
four hours, doses of \ of a grain are sometimes well tolerated. It is well 
to employ general massage at the same time, and, as the pain subsides, 
massage and vibrations to the tender area and sensitive points may be 
added with advantage. As a last resort, operation may be advised, but 
only when a careful, intelligent, and persistent use of general and spe- 
cial measures has failed, or there is evidence of organic changes in the 
nerve or nuclei. There are three general varieties of operations upon 
the trifacial : (1) Those for the purpose of section, exsection, stretching, 
divulsing, or twisting out the various branches at some point below the 
floor of the skull ; (2) those directed to enucleation of the trifacial gan- 
glion ; (3) division of the sensory root of the fifth above the ganglion. 
Operations upon the ganglion are very difficult and dangerous. Fre- 
quently, the eye on the same side has been lost. The operation of 
Horsley, in which the skull is opened and the sensory root divided 
beneath the pons, is much less mutilating and disfiguring, but seems to 
be attended by danger to life. After root divisions the fibers degenerate 
upward, 1 thereby producing a permanent result. This operation is 
worthy of more frequent employment, in spite of its difficulty and 
danger. Spiller and Frazier 2 modify this proceeding by reaching the 
sensory root above the ganglion but outside the skull, the operation 
being carried out precisely on the lines of excision of the ganglion. 
Operations on the branches below the ganglion usually give temporary 
freedom from pain, but relapses are common in the same or in adjoining 
branches. (For details the student is referred to surgical works.) 
Fortunately, with proper systemic and local treatment these severe 

1 L. F. Barker, "Jour. Am. Med. Association." May 5, 1900. 

2 "Phila. Med. Jour.," Dec. 14, 1901, and ibid., Oct. 25, 1902. 



666 SYMPTOMATIC DISORDERS. 

operations are very rarely demanded. As the slighter ones of neurec- 
tomy, etc., occasionally give permanent relief, they should be tried first. 
Since Schloesser in 1900 began the treatment of these neuralgias by the 
intraneural or perineural injection of 80 per cent, absolute alcohol, re- 
ports have come from many sources tending to show that when well 
executed the measure is nearly always promptly palliative and very fre- 
quently curative for a period of months or years. The method consists 
in reaching the involved branches, as near their exits from the skull as 
possible, by means of a blunt, hollow needle, and injecting into or around 
them one to two c.c. of the alcoholic solution. Peripheral tingling and 
numbness show that the proper location has been reached, and after a 
few days sensation returns. The injection sometimes requires several 
repetitions at short or lengthy intervals. An excellent resume" of the 
subject and technique has been published by Hecht. 1 This method 
should always be employed before resorting to cutting operations. 



CHAPTER II. 
DISORDERS OF SLEEP, 

The disorders and disturbances of sleep, while mainly symptomatic, 
in some instances reach an important development and almost attain the 
dignity of a disease. Sleep may be defined as a recurring, necessary 
state of lessened muscular, mental, and organic activity, attended by 
comparative unconsciousness of surroundings. No physical or mental 
function is absolutely abeyant. Respiration, circulation, metabolism, 
catabolism, muscular movements, and dreams demonstrate the persist- 
ence of functional activities. Entirely dreamless sleep probably does 
not occur. Sleep, therefore, is a composite which may be variously 
disintegrated. Sleep-walking, talking in the sleep, nightmare, night- 
terrors, and nocturnal enuresis, may be considered as localized or partial 
sleeplessness. In somnambulism the motor apparatus is awake, as it is in 
night- terrors. In enuresis we have a somnambulism of the lumbar cord, 
to adopt a term from the French. Of the physiology of sleep, though 
it is more necessary to life than food, we know comparatively little. 

Physical Features of Sleep. — In sleep there is muscular relaxation. 
The lids are lowered over the upturned eyeballs ; the expression is one 
of repose. Respiration is slower and less deep. Mosso states that the 
amount of air inspired by a normal man during sleep is one-seventh 
of that used during similar periods of quiet wakefulness. Breathing 
is distinctly thoracic in character, the diaphragm acting but slightly ; 
inspiration is more prolonged and the respiratory pause is absent. There 
is a decrease in carbonic acid elimination and an increase in the absorp- 
tion of oxygen. The circulation presents important modifications. The 
pulse is less rapid. The superficies of the body has an increased vascu- 
larity and is often reddened; there is lowered arterial pressure and a 
1 "Jour. Amer. Med. Assoc," Nov. 9, 1907. 



DISORDERS OF SLEEP. 



667 



smaller central circulation. 1 The brain is comparatively anemic. The 
arterial changes take place in a precise way, increasing with some 
rapidity during the first hour, maintaining a maximum for an hour or 
two, and then gradually decreasing to the waking moment. Such 
curves have been shown by the plethysmograph and correspond fairly 
well to those indicating the depth of sleep as demonstrated by Kohl- 
schutter and others. In accordance with universal experience, the first 
few hours of sleep are, therefore, most profound, refreshing, and valu- 
able. The thorax and limbs actually increase in size during sleep, 
owing to the circulatory conditions ; and we readily comprehend the 
increased activity of the shin, the tendency to night-sweats, and the ease 
with which one is chilled during sleep. Lombard, Eosenbach, and 
others have observed that the muscle reflexes are exaggerated just before 



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HOURS OS 1.0 t.S 2.0 25 3.0 JLS 40 *tJS S.0 SS 6,0 6JS 7.0 7.S 7.8 

Fig. 268.— Curve illustrating strength of auditory stimulus (falling ball) necessary to waken a 
sleeping person. The hours are marked below, and the tests were made at half-hourly intervals. The 
curve shows that the height from which the ball must be dropped reaches its maximum at the end 
of the first hour (Kohlschutter). 

and during the early moments of sleep, but gradually subside, and the 
knee-jerk may even disappear. Slight disturbances tending to awaken 
the individual are attended by a corresponding increase in the reflex 
activity and the central circulation. We are all familiar with sudden 
startings when dropping off to sleep — a manifestation of the increased 
reflex excitability, constituting one of the epiphenomena of sleep. 
The pupils are contracted in proportion to the profoundness of the sleep. 
Requirements for Sleep. — Individuals vary greatly in the amount 
of sleep required, and at different ages there are different needs. While 
some few adults find four or five hours sufficient, the great majority 
demand eight or ten. There are also temperamental differences and 
many variations, the result of habit and circumstances. Crichton Brown 
says that at four years twelve hours' sleep are needed ; at fourteen years, 
ten hours ; at seventeen, nine and one-half hours ; then seven or eight 
hours during adult life. In old age continuous sleep is rare, and the 
requirement is less; but frequent naps and dozing, by day as well as at 
1 Howell, "Jour, of Experimental Med.," 1897. 



668 SYMPTOMATIC DISORDERS. 

night, maintain a fair average. Infants may sleep most of the twenty- 
four hours. More sleep is required in cold than in temperate or warm 
countries. 

Conditions Favoring Sleep. — A cool, dark, quiet, well- ventilated 
room, a comfortable bed, and adequate, not excessive, covering, are 
conducive to sleep. A preparatory period of sleepiness is natural, and, 
in cases of insomnia, must be cultivated. Active emotions, mental 
worries, intense thought, cold extremities, or a chilled skin defeat the 
rearrangement of the circulation, on which so much depends. No 
physical function is so readily disturbed as sleep. If a person is 
awakened at an unusual hour several nights in succession, he tends to 
establish a habit of awakening at that hour. Habit is all-powerful, 
both for good and evil, in this matter. Regular hours for retiring and 
awaking are most important. The use of hypnotics to put patients to 
sleep regularly for a few nights do good mainly by reestablishing the 
natural initiative. 

Disturbances of sleep are (1) those presenting a deficiency, and 
(2) those marked by a morbid increase of sleep. 

WAKEFUL DISORDERS OF SLEEP. 

Insomnia. — Insomnia is a symptomatic condition, marked by more 
or less inability to sleep the individual's usual required length of time. 

Etiology. — The causes of sleeplessness are numerous. Practically, 
every deviation from health is marked by disturbance of sleep ; but in 
many instances, once a bad sleep habit is established, it tends to persist, 
and may be the chief complaint of the patient. Many persons are heredi- 
tarily poor sleepers. In such instances every trivial sound or unusual 
circumstance — a light, an odor, ajar, or even the discontinuance of a cus- 
tomary noise or light — may arouse them. Hunger, over-feeding, indi- 
gestion, constipation, intestinal worms, lithemia, uremia, various drugs, 
tea, coifee, tobacco, alcoholism, fevers of all sorts, malaria, syphilis, 
lead-poisoning, cerebral hyperemia or anemia, as from cardiac disease 
or diathetic states, psychic disturbances, discomfort, pain, neurasthenia, 
grief, worry, old age, mental preoccupation, and intense study are among 
the principal inciting causes of sleeplessness. 

Symptoms. — Some patients readily fall asleep, but shortly awake, 
and are then sleepless the balance of the night, or merely secure fitful 
periods of sleep. Others spend several hours getting to sleep, and may 
then rest fairly well. Still others complain of broken sleep, the night 
being passed in intervals of sleep and Avakefulness, which may be quite 
uniform in a given instance. As a rule, patients troubled with insomnia 
are disposed to exaggerate the amount of sleeplessness, and it is a common 
experience to find such patients sleeping soundly at times, or even for 
much of the night, if they are put under watch. Much loss of sleep 
manifests itself in a haggard, weary air, and in lessened muscular and 
mental force. Appetite, digestion, energy, courage, and good nature 
are diminished. The patient loses weight, and, in cases of absolute 
sleeplessness, the loss may equal that due to deprivation of food. The 



DISORDERS OF SLEEP. 559 

eyes lose their clearness and look dull, and the sclerotic may be con- 
gested. The tongue is coated, constipation may be present, and the 
entire organism is deranged. 

Treatment. — The treatment of the symptom insomnia implies the 
management of the basic condition of which it is a manifestation. All 
hereditary, digestive, toxic, circulatory, nervous, and reflex causes must 
be systematically investigated. The examination of a patient complain- 
ing of insomnia omits nothing. Very frequently, modes of living, and 
especially bad sleep-habits, must be corrected before any improvement 
is secured. The physical state often requires to be thoroughly well 
reestablished by baths, proper diet, exercises, and good hygiene. Atten- 
tion at once falls upon the conditions favoring sleep, as previously outlined. 
The patient must be instructed in the importance of these minutiae, and 
not expect to secure complete relief by a few doses of medicine. As 
adjuvants, a warm bath, taken quietly at bedtime, not followed by 
stimulating frictions, is conducive to sleep. A cold pack or an alcohol 
rub acts well in some cases. The stomach should not be empty. A 
glass of hot milk, or milk and water, or malted milk, or hot lemonade, 
or even of hot water, acts beneficially in decongesting the head in cases 
not anemic. With the hot bath it favors the dilatation of the cutaneous 
vessels, and establishes the circulatory conditions found in natural sleep. 
In the same way a pint of beer not only starts the abdominal organs, 
but flushes the skin. Large doses of whisky are never advisable, 
although sometimes efficient for a night or two. Anemic cases require 
cardiac stimulants and blood-makers. 

Any drug that sufficiently masters the organism to produce sleep is 
a dangerous remedy, and should be used with circumspection, and only 
as a last resort. Of all the hypnotics, chloral alone is uniformly reli- 
able. In cases attended with much nervousness it is decidedly assisted 
by the addition of sodium bromid in equal amount. The administration 
of hypnotics should be done with a definite purpose. It is important to 
exhibit whichever one is selected at such time that its systemic effect 
may be operative when the sleeplessness is due. In cases experiencing 
difficulty in getting to sleep chloral may be given thirty minutes before 
retiring. Cases awakening at one or two o'clock may be given trional, 
in dry powder, at bedtime, as its action is liable to be delayed for a few 
hours. A sufficient dose should be used to have a decided effect, repeated 
several nights, if its action meets the requirements, and then discontinued. 
In some instances three-grain doses every two hours after mid-day act 
much better than a large dose at bedtime. Veronal is so tardy in its 
action, and so depressing during the following day, that it can rarely be 
used with much satisfaction. If the underlying cause has been corrected, 
the proper routine will thereby be reestablished in a few nights. Finally, 
some cases only yield after a complete change of scene. An ocean or 
lake voyage is especially valuable, as it is devoid of exhausting excite- 
ment and sight-seeing. 

Somnambulism. — In sleep-walking the individual acts his part of 
a dream. The motor apparatus is awake and responsive to the mind. 
It is sleep with motor automatic activity, and presents a peculiar 



670 SYMPTOMATIC DISORDERS. 

increase of the subjective powers of the affected person. There is 
often great keenness of touch and analgesia combined. The special 
senses may be active or not, but the patient only takes cognizance of 
those things which pertain to the dream-story. Usually , the pupils do 
not respond to light, and the face has a blank, apathetic appearance. 
The eyes may be open or closed. The sleep-walker has no subsequent 
waking recollection of his somnambulistic acts ; but these may be 
revived or repeated in a subsequent attack. Talking in the sleep is a 
minor degree of somnambulism, and the state of double-consciousness 
may be considered as its largest development. 

Somnambulism may ordinarily be considered as a neurotic stigma, 
and is commonly encountered in those of a neuropathic heredity. 
Puberty is the ordinary age for its appearance, and both sexes are then 
about equally affected. Later in life there are more female than male 
cases. The individual attack is often traceable to some mental prece- 
dent condition. Even the suggestion of sleep-walking, in the discus- 
sion of the subject, has led to its appearance. In other cases the 
patient carries out in sleep the line of action on which he had been 
intent before retiring. In most cases presenting repeated attacks there 
is a similarity of action in all of them, or one attack may continue the 
action of its predecessor. 

The treatment of the condition should be broad enough to cover the 
neuropathic make-up of the patient, and is most successful in proportion 
as it is directed to the mental element in the disturbance. If the 
patient takes with him to bed a firm intention not to walk, it is often 
sufficient to inhibit the attack. In nervous subjects of impaired self- 
control a vigorous suggestion, that will be operative during sleep, must 
be implanted. This, in children, may be accomplished by a system of 
rewards or deprivations, by a cold spinal douche at bedtime, associated 
with the suggestion that it is to prevent walking during the night, or 
by an emphatic admonition from a respected source. The individual 
attack may be brought to an end by a dash of cold water, or a sharp 
puff of breath in the face, or by firm pressure over the supraorbital 
foramina. So rude a shock may be curative, but in highly nervous 
children is to be used with caution. In adult cases, with frequently 
repeated attacks, any plan of treatment is likely to fail, and in some 
instances nightly precautions are necessary to guard against accidents. 

Dreams. — Dreaming is perfectly physiological. As already stated, 
it is probable that dreamless sleep does not occur. Only those dreams, 
however, are remembered that are particularly vivid or occur during 
light sleep, the ordinary condition after the third hour. In numerous 
experiments it has been found that sleepers, suddenly and unexpectedly 
aroused, can always give an account of the interrupted dream. Dreams, 
however, have a considerable medical importance. In lowered nervous 
or physical states the sleep is not profound, and the patient complains of 
dreaming constantly. The nature of the dreams has a general relation 
to the physical and mental status. Only the well have contented, happy 
dreams. Neurasthenics, hysterics, and melancholiacs are tormented by 
troubled dreams of an unhappy, depressing character. Neurasthenics 
and hysterics are prone to have some particular, formulated dream that 



DISORDERS OF SLEEP. 671 

occurs several times in a night or on different nights. The influence of 
a terrifying dream in hysteria may equal a severe mental shock in the 
waking moments, and may be the basis of a hysterical, fixed idea, leading 
to paralysis, anesthesia, contracture, or assertion of attempts upon 
chastity (Janet). 

In some nervous conditions the dream state is projected into the 
waking state for a few moments, or for a longer time. In hysteria the 
features of the dream may then persist for an hour or more, constituting 
a delirious accident. It is a sort of somnambulism, but with greater 
mental and physical activity. Or the dream may evoke a convulsive 
crisis. Of the same nature, perhaps, is sleep-drunkenness, or somnolentia, 
in which a person, on being suddenly awakened from deep sleep, is 
apparently maniacal, and may do acts of violence. A great interest in 
dreams has followed Freud's studies of the dream state. He insists that 
during sleep, judgment being reduced, the natural tendencies as well as 
the morbid ones are unhampered, and subjective states prevail. By a sys- 
tematic study of the dream content he thus frequently discovers the fixed 
or dominant idea controlling hysterical and psychasthenic manifestations. 

In pavor noeturnus, commonly called night-terrors, and occurring 
only in children, the little patient awakes in vague, wild alarm one or 
two hours after going to sleep. The child screams in terror, clings to 
its mother, but apparently fails to recognize any one, and can not be 
quieted or reassured. After a few minutes or more the excitement 
spontaneously subsides and the child returns to sleep without recollec- 
tion of the attack in the morning. During the frenzied terror the 
patient may run from the room, or climb upon the furniture, in a wild 
effort to escape something. Often the cries imply a fear of being caught 
by some one or by wild animals. 

True pavor noeturnus is of somewhat serious import, as it indicates 
an unstable nervous constitution, and is a frequent item in the early 
history of epileptics. Some writers consider it a true neurosis, and, at 
least, it is a stigma of degeneracy. It is often apparently induced by 
respiratory difficulty dependent upon faucial adenoids, bronchitis, laryn- 
gitis, weak heart, or general asthenia. In mild form it may only suggest 
nightmare or incubus, which is a vivid dream, usually traceable to some 
physical condition or previous terrifying experience. Indigestion, bad 
ventilation, or mental shocks, fright, worry, etc., give rise to nightmares 
attended by a feeling of a great weight on the chest, suffocation or 
falling. Ordinarily, at such moments the patient suspends respiration, 
or makes distressed inspiratory noises and awakens with a start. 

Nocturnal enuresis is a common disorder in weakly and neurotic 
children. Neurasthenics, hysterics, epileptics, and the entire range of 
neuropaths give abundant testimony on the subject of bed-wetting. In 
certain instances it undoubtedly is an automatic action, a partial som- 
nambulism. The patient dreams he is passing water, and voids his urine 
accordingly. The same mechanism may operate in the more frequent 
form. Parents report that when this occurs under observation the 
bladder acts forcibly, and the stream is propelled with vigor. It is not 
a mere sphincteric relaxation, as is sometimes alleged. Such children, 
if taken up at night and made to urinate, may repeat the act almost 



672 SYMPTOMATIC DISORDERS. 

immediately upon being put back to bed, perhaps through suggestion. 
It is probable that slight distention of the bladder, or the presence of a 
drop or two of urine in the vesical end of the urethra, gives rise to sensa- 
tions which set up a chain of ideas eventually leading to the urinary act. 
It is definitely proven that various external stimuli — as sounds, voices, 
lights, etc. — may be partially apprehended by the sleeper and woven 
into his dreams, materially modifying their trend. Internal sensations 
are no less liable to act in the same manner, and are generally accredited 
of doing so in nightmare. 

The management of nocturnal enuresis demands attention to several 
factors : First, the general condition of health ; second, the reduction 
of nervous excitability ; third, the prevention of a large vesical accumu- 
lation ; fourth, — and perhaps the most important of all, as in somnambu- 
lism, — the establishment of a definite idea of self-control. It is well to 
withhold liquids toward the evening, and to have the child thoroughly 
evacuate the bladder at bedtime. Elevation of the foot of the bed by 
several inches, to gravitate the urine from the neck of the bladder, has 
been strongly recommended by Mendelssohn. Belladonna reduces vesi- 
cal irritability, and the urine should be rendered unirritating. Local 
disturbance in bladder and urethra must be removed and worms ex- 
pelled. Finally, a strong mental impression is of the greatest value. For 
instance, Prendergast 1 cured seventy-five out of eighty cases in a boys' 
orphanage within a short period of time by giving them a cold spinal 
douche, followed by a quick rubbing-down just before getting into bed. 
Nothing else whatever was done, and the five remaining cases were much 
improved. In some cases the first douche had the necessary effect, and 
the mind remained on guard. 



SOMNOLENT DISORDERS OF SLEEP. 

The second group of sleep disorders comprises those marked by 
somnolence, or by an irresistible tendency to sleep. 

Narcolepsy is a condition in which the patient repeatedly goes to 
sleep during the day. The tendency is irresistible, and the morbid 
sleep may last a few minutes or several hours. It furnishes one of the 
accidents of hysteria, and may be dependent upon drugs, brain disease, 
gout, obesity, uremia, diabetes, and syphilis. Some neurotic families 
present a number of instances of narcolepsy, associated or alternating 
with severe neuroses, mainly hysteria and epilepsy. It may be an epi- 
leptic equivalent, and many cases also present epilepsy. It should 
always suggest the possibility of epilepsy or hysteria if defective nutri- 
tion and the systemic states mentioned can be excluded. In some 
instances ocular fatigue, due to refractive errors, seems to be the start- 
ing-point for the attacks, which are overcome by appropriate glasses. 
In some instances the sleep in such attacks is disturbed, and the patient 
may have vivid dreams and talk in a flighty manner. In other cases, as 
in epilepsy, the patient is comatose and can not be aroused. In the ma- 
jority of cases the sleep is deep and no dream recollections are obtainable. 
1 "New York Med. Jour.," July 11, 1896. 



DISORDERS OF SLEEP. 673 

Treatment depends upon deciphering and removing the cause, and 
then breaking up the habit. For this purpose caffein and nitroglycerin 
or nitrate of amyl, to control the cerebral circulation, are available. 

Sleeping Sickness. — On certain African coasts the natives are 
affected by a parasitic disease. Somnolence appears at intervals and 
gradually increases, until the patient sleeps steadily, at first arousing 
sufficiently to take food, and finally not awaking under any stimulus. 
In two cases carefully observed by Mott, 1 a chronic diffuse leptomeningitis 
and encephalomyelitis were found, but no infectious organism. Later 
observations sufficiently confirmed show this disease to depend upon the 
invasion of trypanosomes inoculated by the "tstse" fly. They cause a 
diffuse chronic lymphadenitis leading to a chronic interstitial inflamma- 
tion of the lymphatic structures of the brain and cord. Death usually 
results from inanition in four or five months, but patients have lived for 
two or three years. Treatment by atoxyl, an arsenical preparation, 
appears to be specific. 

Trance, catalepsy, and ecstacy are hysterical accidents — fractional 
hysterical convulsions extended into status. They are described, with 
their treatment, in the discussion of Hysteria. 



SLEEP PALSIES. 

Persons with disordered systemic conditions — as in anemia, gout, 
diabetes, women at the menopause, excessive users of tobacco, etc. — may 
awake with benumbed extremities. The hands and feet are most 
affected, giving origin to the term acroparesthesia. The sensations are 
described as pricking and numbness, as being " asleep," and some 
cramping and decided pain may occur. A loss of power is noted if the 
condition is marked. The disturbance lasts a few minutes or an hour, 
and is usually relieved by friction and exercising the members. Less 
frequently one limb only is affected, or both limbs on one side. This 
affection may occur nightly for months and years, and appear during 
the day also if the patient fall asleep. Its treatment is that of the 
underlying state. 

In sleep, especially the profound sleep of drunkenness or the coma 
of anesthesia, pressure on a nerve may set up a neuritic palsy. This 
is particularly common in the musculospiral, but in operations on the 
perineum and pelvic contents the lithotomy position is capable of injuri- 
ously stretching the sciatic. The brachial plexus may be injured by 
elevating the arm too forcibly in operation on the breast, or by the 
anesthetizer. These are hardly to be called sleep palsies, but are 
definite accidents occurring during sleep. 

Anemic neurasthenic patients sometimes have difficulty in opening 
the eyes in the morning, but if the lids are once raised by the finger, 
they tend to remain open. The symptom is called sleep ptosis, is 
usually transient, and commonly passes away with the myasthenia of 
which it is part. This, or a similar condition, occurs as a part of my- 
asthenia gravis or pseudobulbar paralysis, but in such cases is caused 
or increased by fatigue and tends to subside during sleep. 
1 "Br. Med. Jour.," Dec. 16, 1899. 

43 



674 SY3IPT03IATIC DISORDERS. 



HYPNOTISM. 

Hypnotism is an artificial, morbid, sleep-like condition produced in 
susceptible persons by various methods. In it the complex of sleep is 
more or less disaggregated. Attention within a limited field and auto- 
matic motor activity may be retained, but mental initiative, volition, 
and judgment are much impaired. The acts and circumstances of well- 
marked hypnotic conditions can not be recalled by the subject unless 
the hypnosis is revived. It is, therefore, a state of subconsciousness or 
double consciousness. Different experimenters find varying proportions 
of susceptible individuals. The sexes are about equally hypnotizable. 
Those of mediocre self-consciousness, those accustomed to unquestion- 
ingly obey, — hence, children and some hysterics, — are the most ready 
subjects. A great deal depends upon the preparatory conditions and 
the belief or skepticism of the patient. In those places where daily 
stances of hypnotism are held and the subject is introduced into an 
atmosphere of faith and observes the process in others, success in the 
method is naturally greatest. Experience on the part of the hypnotizer 
is also an important factor. The whole matter consists of building up 
an expectant attention. Low-grade idiots, most of the insane, and many 
hysterics, incapable of exercising continuous attention, are not hypnotiz- 
able by ordinary methods. The state is purely subjective to the one 
operated upon. After a person has once been hypnotized, he subse- 
quently more readily enters hypnosis, and finally the condition is pro- 
duced almost at a hint. In extreme cases it may be automatically 
evoked by anything which suggests the method employed in the given 
case, and the subject becomes the puppet of a trivial sound or flash of 
light. During hypnosis there is a high degree of suggestibility, so that 
the subject apparently unquestioningly accepts the dictum of the operator. 
In somnambulism the special senses and general sensibility may be ex- 
tremely acute or entirely blunted, responding only along the various lines 
of the hypnotic field of activity. Autohypnosis is also possible, and is a 
common trick of East Indian fakirs and dime museum tricksters in this 
country. 

Methods of Hypnotizing. — After the subject is prepared by ex- 
ample or explanation and his cooperation secured, the most common 
plan, that of Braid, is to cause ocular fatigue by having the patient fix 
the eyes in unwinking gaze upon a small, bright object held about six 
inches distant and above the ordinary line of vision. This shortly 
produces a feeling of fatigue in the ocular muscles, the eyes water, the 
lids tremble, and the operator, by suggesting sleep, adds to the mental 
impression of drowsiness. Passes of the hand over the head or down 
the limbs may be added. Their soothing effect is well known, and soon 
the eyes close, or the lids are pressed down by the operator, who enjoins 
the patient to " sleep, sleep soundly, deeper yet, deep sleep/ J etc. Four 
or five minutes may be required for this performance, the patient being 
placed in a reclining or comfortable attitude for sleep. At this point 
the subject is firmly and authoritatively told that his eyes are closed, 



DISORDERS OF SLEEP. 675 

that he is asleep, that he can not open his eyes. The operator may 
start the subject's hands in rotation and command him to continue the 
movement, asserting that he can not stop until ordered, etc. Other 
methods contain the same elements of suggestion and are aided by the 
operator's voice in a similar manner. Thus, continuous gentle pressure 
on the eyeballs, passes, and stroking, monotonous sounds, fixing the 
attention, or gazing fixedly at small revolving mirrors (Luys), the 
patient meanwhile sitting in a darkened room, are among the methods 
frequently used. A loud sound or a vivid flash of light, after due prep- 
aration, may throw the subject at once into deep hypnosis (Charcot). 
Bernheim fixes the patient's gaze with his own and suggests sleep : 
" Sleep is approaching, your limbs are feeling warm and gently tingling, 
your eyelids are heavy, you are going to sleep ; you are sleeping, sleep 
soundly," etc. The subject is aroused by command, by a puff of air 
in the face, or by stroking the head. If left to himself, he sponta- 
neously emerges from the hypnosis after a variable time, a few minutes 
or an hour or two. 

The hypnotic state varies in intensity from slight torpor to somnam- 
bulistic automatism. Only a small percentage of subjects can be put 
into the deepest phase ; and it is rarely required, as, for purposes of 
therapeutic suggestion, the lighter phases are quite sufficient. Charcot 
divided the hypnotic state into three phases — the lethargic, the cataleptic, 
and that of somnambulism. In the first the subject is as if asleep, 
without changes of respiration, pulse, or temperature. There is usually 
some analgesia, but the operator's voice is heard and the subject replies 
to questions. In the cataleptic stage the limbs retain the position given 
them, or, if set in motion, continue the movement indefinitely, analgesia 
is complete, and commands are obeyed within the cataleptic range. In 
somnambulism the subject is automatically responsive in every way to 
the operator, whom alone he sees, hears, or obeys, unless otherwise in- 
structed. Suggestions are implicitly accepted, regardless of their non- 
sensical or irrational character, and commands that do not contravene 
deep-seated moral convictions are unquestioningly executed. Subse- 
quently, the subject has no recollection of his automatic acts or of the 
conditions under which they were performed, but, rehypnotized, can 
readily reproduce them. 

Uses of Hypnotism. — In spite of the extravagant claims for the 
therapeutic value of hypnotism, it is as yet of very little service to the 
physician. Now and again a minor operation may be done under its 
influence, saving the slight risk of surgical anesthesia, or by its aid a 
fixed idea may sometimes be removed and a delusion dispelled. Under 
ordinary circumstances the number of susceptibles is so small that its 
general use is impossible. In hysteria, as elsewhere, it is a two-edged 
weapon, and the patient may emerge from hypnosis instituted for a minor 
difficulty and go into severe hysterical convulsions. One delusion may be 
removed, but another and more serious one of mind -reading or undue 
influence may 'be implanted. For obvious reasons, women should never 
be hypnotized without reliable witnesses, and the public use of hypno- 
tism can only appeal to the morbid. In this connection its power for 



676 SYMPTOMATIC DISORDERS. 

harm is proven. There is no longer any doubt that its frequent repe- 
tition is harmful to the individual. It tends to destroy self-reliance 
and to make patients imaginative, weak-minded, and neurasthenic. It 
also has a tendency to bring discredit upon its employer, and in most 
instances would better be substituted by measures of equal efficiency 
and less disadvantage. Suggestion, however, is a mighty aid to the 
physician, and, without producing hypnosis, positive and intelligent 
assertion can accomplish all that is likely to be done by hypnotism 
short of the somnambulistic stage. A fair realization of the part sug- 
gestion plays in therapeutics is one of the recent achievements of the 
most progressive medical minds. 



MENTAL DISEASES 



BY 



FREDERICK PETERSON, M. D., 

EX-PRESIDENT OF THE NEW YORK STATE COMMISSION IN LUNACY ; PROFESSOR OF 

PSYCHIATRY, COLUMBIA UNIVERSITY; CONSULTING ALIENIST, BELLEVUE 

HOSPITAL; MANAGER OF THE CRAIG COLONY FOR EPILEPTICS, 

AT SONYEA, NEW YORK ; EX-PRESIDENT OF THE 

NEW YORK NEUROLOGICAL SOCIETY. 



MENTAL DISEASES. 



CHAPTER I 



INSANITY. 



Synonyms. — Psychosis, Psychopathy. German: Irrsinn, Irresein, Verriicktheit, 
Wahnsinn. French : Alienation mentale, Folic 

It is the object of the author to bring together in the following 
chapters such matter in relation to the definition, classification, etiology, 
pathology, symptomatology, and treatment of insanity as will be of 
actual practical value to the medical student and general practitioner. 

The seeker after special information and deeper knowledge of the 
complex subject of morbid psychology must be referred to the many 
profound works which deal with this exclusively. These chapters are 
based upon my clinical lectures given at the Vanderbilt Clinic during 
the past twenty years, to the students of the College of Physicians and 
Surgeons of Columbia University. They, therefore, embody only the 
tacts which I believe to be the most serviceable and useful to those who 
are often practically concerned with the early diagnosis and prognosis of 
insanity, and who must be the first arbiters as to the course of care and 
treatment to be pursued. 

Definition. — The difficulty of making a rigid definition of insanity 
is recognized by all who have attempted it. So various are the mani- 
festations of mental aberration, so many the faculties involved, so differ- 
ent the degrees of deviation from the normal, it is no wonder that the 
expert hesitates and often fails in the effort. The definition, too, must 
include idiocy, and must exclude certain states of transitory mental dis- 
order, such as the delirium of fevers and of intoxications. 

The noted English jurist, Lord Justice Blackburn, once said, while 
giving evidence before a committee of the House of Commons : " I 
have read every definition which I could meet with, and never was 
satisfied with one of them, and have endeavored in vain to make one 
satisfactory to myself. I verily believe that it is not in human power 
to do it." 

Fortunately, we are not often called upon to give a definition of 
insanity, and usually we may reply that insanity is a symptom of so 

679 



680 MENTAL DISEASES. 

many obscure pathological states, and appears in such divers forms that 
a narrow definition is not possible. However, the practitioner may 
find himself in the witness-box some day, and it is not uncommon for 
one of the legal examiners to ask of the witness in a mental case a defi- 
nition of insanity. If the witness be wise, he will answer as indicated, 
or he may qualify such answer by offering to quote some one of the 
definitions given by alienists, such as follow : 

A disease of the brain (idiopathic or sympathetic) aifecting the in- 
tegrity of the mind, whether marked by intellectual or emotional dis- 
order. — (Hack Tuke.) 

A special disease, a form of alienation characterized by the acci- 
dental, unconscious, and more or less permanent disturbance of the 
reason. — (Regis.) 

Morbid derangement, generally chronic, of the supreme cerebral 
centers, — the gray matter of the cerebral convolutions or the intellecto- 
rium commune, — giving rise to perverted feeling, defective or erroneous 
ideation, and discordant conduct, conjointly or separately, and more 
or less incapacitating the individual for his due social relations. — 
(Maudsley.) 

Insanity is either the inability of the individual to correctly register 
and reproduce impressions (and conceptions based on these) in sufficient 
number and intensity to serve as guides to actions in harmony with the 
individual's age, circumstances, and surroundings, and to limit himself 
to the registration as subjective realities of impression transmitted by 
the peripheral organs of sensation, or the failure to properly coordi- 
nate such impressions and to thereon frame logical conclusions and 
actions, these abilities and failures being in every instance considered 
as excluding the ordinary influences of sleep, trance, somnambulism ; 
the common manifestations of the general neuroses, such as epilepsy, 
hysteria, and chorea ; of febrile delirium, coma, acute intoxications, 
intense mental preoccupation ; and the ordinary immediate effects of 
nervous shock and injury. — (Spitzka.) 

With these few examples before us of the diversity of definition 
attained by careful students of psychiatry, we may well content our- 
selves and acknowledge that a satisfactory definition in brief form is 
scarcely to be devised. The writer has often qualified this by offering 
the following, which has at least the merit of brevity, if not of perfect 
adequacy : 

Insanity is a manifestation in language or conduct of disease or defect 
of the brain. 

The law assumes to offer certain definitions of insanity, from which, 
however, those of medicine would tend to differ, in connection with the 
three chief points where law and psychiatric medicine meet : 

1. A criminal is insane if he does an act whose nature and quality 
he does not know, or if, knowing the nature and quality of his act, he 
does not know whether it is right or wrong. 

2. A testator is insane if his mind, memory, or understanding is 
unsound. 

3. In a lunacy inquisition the subject of the inquiry is insane if he 



INSANITY. 681 

is incapable of managing himself and his affairs. Such are the diver- 
gent tests of insanity in law. 

Classification. — What has been said of the difficulty of denning 
insanity is equally applicable to classification. Not all of the writers 
of works on psychiatry have deemed it expedient to offer a definition 
of insanity, but there is scarcely one who has not presented us with an 
original classification, or one modeled upon, or modified from, that of 
his favorite authority. It will be impossible as well as useless to 
attempt to enumerate in these pages one-half of the many classifications 
which have been made, held for a time, and finally abandoned with the 
advance of science and the accumulation of new facts in the domains 
of pathology and psychology. It suffices to say that there are at least 
forty such classifications which have been made upon etiological, psy- 
chological, symptomatological, or pathological grounds. I shall present 
here, simply as examples for reference, several of the latest and best 
classifications of the Anglo-American, German, and French schools. 

The Statistical Committee of the Medico-psychological Association 
of Great Britain adopted the following classification for use by the 
medical superintendents of asylums : 

1. Congenital or infantile mental deficiency — 

a. With epilepsy. 

b. Without epilepsy. 

2. Epilepsy (acquired). 

3. General paralysis of the insane. 

4. Mania — receul. chronic, recurrent, a potu, puerperal, senile. 

5. Melancholia — recent, chronic, recurrent, puerperal, senile. 

6. Dementia — primary, secondary, senile, organic, — i. e. , from tumors, coarse brain 

disease. 

7. Delusional insanity. 

8. Moral insanity. 

Maudsley's grouping is as follows : 

I. Affective or Pathetic Insanity. 

1. Maniacal perversion of the affective life (mania without delusion). 

2. Melancholic depression without delusion (simple melancholia). 

3. Moral alienation proper approaching this, but not reaching the degree 

of positive insanity in the insane temperament. 



IT. 


Ideational Insanity. 






1. 


General. 

a. Mania. 


f acute. 






b. Melancholia 








( chronic. 




2. 


Partial. 

a. Monomania. 

b. Melancholia. 

( primary. 






3. 


Dementia < 








( secondary. 




4. 


General paralysis. 






5. 


Imbecility. 





682 



MENTAL DISEASES. 



Classification of the Congress of Paris (1889) 



1. Mania (acute delirium). 

2. Melancholia. 

3. Periodical insanity (circular insanity, etc.). 

4. Progressive systematized insanity. 

5. Vesanic dementia. 

6. Organic dementia. 

7. Paralytic insanity. 

8. Neurotic insanity (hypochondria, hysteria, epilepsy, etc.). 

9. Toxic insanity. 

10. Moral and impulsive insanity. 

11. Idiocy. 



The following is the classification of R6gis : 



I. Functional Insanity. 



Generalized 

or 
symptomatic. 



1. Mania. 



2. Melan- 
cholia. 



Subacute mania (maniacal excitation). 
Acuta mania (typical mania). 
Hyperacute mania (acute delirium). 
Chronic mania. 
Remittent or intermittent mania. 

Subacute melancholia (melancholic depres- 
sion). 
Acute melancholia (typical melancholia). 
Hyperacute melancholia (with stupor). 
Chronic melancholia. 
Remittent or intermittent melancholia. 



{continuous, 
intermittent. 

v . . , ( Systematized ( f irst s j a f (hypochondriacal insanity). 

Partial or 1 nrooressive / Second stage (persecutory, religious, erotic, 

essential insanity. ) p . * •+_ j political, etc.). 

( msamt y- Third stage (ambitious insanity). 



II. Constitutional Insanity. 

/ Disharmony (defect of equilibrium, irregularity, eccentricity) 

Degeneracy of \ Neurasthenia (fixed ideas, impulsions, aboulias). 
evolution. / ( delusional. 

(Vices of or- ) Phrenasthenias ■{ reasoning, 
ganization. ) I ( instinctive. 

\ Monstrosities (imbecility, idiocy, cretinism, myxedema). 



Degeneracy of in- 
volution. 
(Disorganization.) 



Dementia (simple dementia). 



Krafft-Ebing has drawn up this scheme : 



A. MENTAL DISORDERS OF THE DEVELOPED BRAIN. 

I. Psychoneuroses. 

C simplex. 

Melancholia < 

I attonita. 

1. Primary curable conditions. ) m«™o f Maniacal exaltation. 

Mama. { Acute mania> 

Stupor^ or curable dementia. 
Wahnsinn (vesania). 



INSANITY. 683 

I Secondary monomania (Vernicktheit). 
( agitated. 
Terminal dementia < 
I apathetic. 
LL Psychic Degeneracies. 

1. Reasoning insanity. 

2. Moral insanity. 

3. Primary monomania (primare Verriiektheit — persecutory, erotic, reli- 

gious, ambitious). 

4. With imperative conceptions. 

f epileptic. 

5. Insanity from constitutional neuroses < hysterical. 

( hypochondriacal 

6. Periodical. 

IIL Cerebral Diseases with Marked Mental Symptoms. 

1. Paralytic dementia. 

2. Cerebral syphilis. 

3. Chronic alcoholism. 

4. Senile dementia. 

5. Acute delirium. 

B. ARRESTED CEREBRAL DEVELOPMENT. 

1. Idiocy. 

2. Cretinism. 

Ziehen has given the following classification : 

I. Psychoses without Intellectual Defect. 

A. Simple psychoses. 

( Mania. 

1. Affective psychoses. -J Melancholia. 

( Neurasthenia. 

Stupidity. 

/ simple. 

) hallucinatory. 

2. Intellectual psychoses. { Paranoia \ ideational (ideenfluchtigeX 

1 stuporous. 

incoherent. 
Imperative conceptions. 

B. Mingled psychoses. 

II. Psychoses with Intellectual Defect. 

a. Congenital weakness (idiocy, imbecility, feeble-mindedness). 

b. Acquired weakness, or dementia. 

1. Paralytic dementia. 

2. Senile dementia. 

3. Secondary dementia (after functional psychoses). 

4 Secondary dementia (after cerebral lesions, syphilis, etc.). 

5. Epileptic dementia. 

6. Alcoholic dementia. 



684 MENTAL DISEASES. 

Kraepelin, who has done so much of recent years to try to bring 
the chaos of classification of insanity into some sort of order, and who 
by his example has so greatly stimulated the clinical study of psychiatry, 
has adopted the following classification : 

I. Infectious Psychoses. 

a. Fever deliria. 

b. Deliria from infections. 

c. States of exhaustion from infections. 

II. Psychoses of Exhaustion. 

a. Collapse delirium. 

b. Acute confusion (amentia). 

c. Chronic nervous exhaustion. 

III. Intoxications. 

1. Acute intoxications. 

2. Chronic intoxications. 

a. Alcoholism (intolerance of alcohol, pathological intoxication, 

chronic alcoholism and alcoholic deterioration, delirium tremens, 
Korsakoff's psychosis or chronic delirium, hallucinatory delu- 
sional states or alcoholic hallucinosis, acute and subacute forms, 
and systematized delirium, hallucinatory dementia or alcoholic 
paranoia, delusions of jealousy, alcoholic pseudoparalysis). 

b. Morphinism. 

c. Cocainism. 

IV. Thyreogenous Insanity. 

a. Myxedematous insanity. 

b. Cretinism. 

V. Dementia Precox. 

Hebephrenic, catatonic, and paranoid forms. 

VI. Paralytic Dementia. 

VII. Insanity with Cerebral Disease (cortical gliosis, diffuse sclerosis, Hunt- 
ington's chorea, multiple sclerosis, syphilis, tabetic psychoses, arterio- 
sclerotic atrophy, circumscribed lesions — tumors, abscesses, hemorrhages, 
embolism, atrophies, and traumatic disorders. 

VIII. Psychoses of the Period of Involution. 

a. Melancholia (simple and hypochondriacal forms, depressive delusional 

states, anxious melancholia). 

b. Presenile persecutory delusional states. 

c. Senile dementia (presbyophrenia, depressions, delirium, paranoid 

states) . 

IX. Manic-depressive Insanity (manic and delirious states, depressive and 
stuporous states, and mixed conditions). 

X. Paranoia (of persecution, of grandeur, erotic, and hallucinatory forms, 
original paranoia, and paranoia of querulants). 

XI. Epileptic Insanity (dementia, periodical moods, delusional states, states 
of obscuration, stupor, anxious delirium, and dipsomania). 



INSANITY. 585 

XII. PSYCHOGENOUS NEUROSES. 

a. Hysterical insanity (hypochondriacal disorders, change of character, 

dream states and deliria, moods and states of agitation). 

b. Neuroses of fright. 

c. Neuroses of anticipation. 

XIII. Original or Constitutional Conditions. 

a. Nervosity (including congenital neurasthenia). 

b. Constitutional depression. 

c. Constitutional excitement. 

d. Imperative psychoses ("manias" and phobias). 

e. Impulsive insanity (kleptomania, etc.). 
/ Sexual psychopathia. 

XIY. Psychopathic Personalities. 

a. The born criminal, and moral insanity. 

b. The unstable (including pseudodipsomania and habitual criminals). 

c. The morbid liars and frauds. 

d. The pseudoquerulants. 

XV. States of Deficient Development. 

a. Imbecility. 

b. Idiocy. 

To any but the expert and special student some of these classifica- 
tions must, indeed, be mystifying and incomprehensible. They are for- 
bidding to the ordinary student and to the general practitioner, and 
might well induce him to shun the realms of psychiatry which open 
before him so uninvitingly and present such obstacles to his progress. 
And the fact is that they are interesting to the specialist alone because 
they are as yet quite impracticable from the standpoint of actual 
utility, as is evidenced by the employment even by the physicians of 
asylums, who are nothing if not practical alienists, of far simpler 
schemes of classification in the preparation of statistics for their annual 
reports and in the histories entered upon their case-books. If the asy- 
lum practitioners are compelled for practical purposes to adopt a simple 
method of classification, how is the novitiate in psychiatric learning to 
surpass them in the diagnosis and grouping of his cases? Here, for 
instance, are two of the latest classifications made for the asylums of 
New York State by the State Commission in Lunacy, assisted by the 
director of the Pathological Institute and a committee of superintend- 
ents of the hospitals (1905). 

The first of these tables is one for statistical purposes only, it having 
been found to be more practical to separate the statistical classification 
from one devoted entirely to clinieo-pathological purposes : 

STATISTICAL TABLE OF NEW YORK STATE HOSPITALS. 

1 . Alcoholic insanity. 

2. General paralysis. 

3. Senile insanity. 

4. Epilepsy with insanity. 

5. Imbecility and idiocy with insanity. 

6. Other psychoses. 

7. Not insane. 



686 



MENTAL DISEASES. 



CLINICO-PATHOLOGICAL CLASSIFICATION OF NEW YORK STATE 

HOSPITALS. 

1. Brain tumor. 

2. Traumatic psychoses. 

3. Psychoses accompanying other nervous diseases. 

4. Senile psychoses. 

5. General paralysis. 

6. Alcoholic psychoses (with subdivision into types). 

7. Morphinism and cocainism, etc. 

8. Infective-exhaustive psychoses (delirious types). 

9. Allied disorders. 

10. Depression not sufficiently distinguished. 

11. Melancholia symptomatic. 

12. Depressive hallucinosis. 

13. Involution melancholia. 

14. Disorders allied to the depressions. 

15. Paranoic conditions. 

16. Dementia praecox. 

17. Allied disorders. 

18. Manic-depressive psychoses (first, second, third, fourth, etc., attack). 

19. Allied disorders. 

20. Constitutional inferiority. 

21. Hysterical insanity. 

22. Epileptic insanity. 

23. Imbecility and idiocy with insanity. 

24. Not classified. 

25. Not insane. 

In the above, the item 9 implies disorders akin in type, but not suf- 
ficiently in etiology, to the toxic and infective-exhaustive processes. Item 
14 covers disorders allied to the depressions (]So. 10 to 13). Item 17 
contains the disorders akin to paranoic conditions and dementia praecox. 

This latter scheme of classification, developed under the Kraepelinian 
influence, has been further slightly modified with time, as evidenced by 
the following table of admissions to the New York State hospitals for 
the year ending September 30, 1909 : 



Psychosis. 



"With brain tumor 

Traumatic = 

Senile 

Dementia paralytica . . . 

"With other brain or nervous diseases .... 

Alcoholic . . 

Drug and other toxic 

Infective-exhaustive and autotoxic 

Allied to infective-exhaustive 

Symptomatic depressions 

Depressive hallucinoses 

Involution melancholia 

Depressions undifferentiated 

Dementia praecox 

Allied to dementia praecox . 

Paranoic conditions 

Manic-depressive 

Allied to manic-depressive 

Epileptic 

Hysterical, psychasthenic, and neurasthenic . 
Other constitutional disorders and inferiorities 

Imbecility and idiocy with insanity 

Unclassified 

Not insane 

Total 



Males. 


Females. 


4 


2 


17 


5 


279 


327 


485 


173 


109 


79 


433 


128 


8 


16 


44 


94 


6 


27 


6 


7 


17 


29 


68 


139 


58 


73 


543 


489 


69 


80 


94 


154 


161 


241 


58 


114 


84 


64 


14 


30 


71 


51 


47 


36 


52 


64 


53 


20 


2780 


2442 



Total. 



6 

22 
606 
658 
188 
561 

24 
138 

33 

13 

46 
207 
131 
1032 
149 
248 
402 
172 
148 

44 
122 

83 
116 

73 



5222 



INSANITY. (337 

I have several reasons for reprinting this instructive table from the 
latest available report of the State Lunacy Commission. In the first 
place, it bears little resemblance to any of the classifications of the 
English, French, or German schools printed above, even to that of 
Kraepelin, which is its main foundation, and well illustrates the futility 
of any classification at all in the present state of our knowledge of the 
pathology of insanity. The diagnoses of these 5149 cases of insanity 
have been made by the practical alienists in our asylums during the 
year stated, and it is fair to assume that they had an average of six 
months for the observation and study of each patient recorded in these 
statistics. If we add to the cases in the list that could not be classified 
at all the cases that are put under headings that are ill defined, hazy, 
confusing, and not clear-cut syndromes, we have the following table : 

Unclassified 116 

With other brain or nervous diseases 188 

Allied to infective-exhaustive 33 

Symptomatic depressions 13 

Depressions undifferentiated 131 

Allied to dementia prsecox 149 

Paranoic conditions 248 

Allied to manic-depressive 172 

Hysterical, psychasthenic, and neurasthenic pychoses 44 

Other constitutional disorders and infirmities 122 

Total 1216 

Now, subtracting from the total admissions the 73 patients that had 
been committed that year and were found not to be insane, we have 
nearly 24 per cent, of the cases in which experts, after an average ob- 
servation for six months, were unable to arrive at a more definite diag- 
nosis of the form of insanity than is shown in the above table. In 
about one case in eight they could not tell whether a case was true de- 
mentia precox or similar to it or allied to dementia prsecox. In nearly 
one case in three they could not decide whether a case was true manic- 
depressive insanity, or somewhat like it, allied to manic-depressive in- 
sanity. In about one in five of the infective-exhaustive psychoses there 
was the same insecurity of diagnosis. This is not recited in criticism 
of the methods of classification in vogue, for I believe that no better 
grouping of cases could be made anywhere than has been done here, but 
is simply brought forward to illustrate the extraordinary difficulty of 
making a diagnosis and classification of the forms of insanity in a large 
proportion of cases. If the asylum experts fail so lamentably, with 
months for investigation of their cases, the general practitioner need not 
feel disheartened if he is unable to make a correct diagnosis after seeing 
a patient once or twice, or if later any diagnosis of his should prove to 
be incorrect. If he calls a case by the old term melancholia, he will be 
forgiven if later it should find a place among the finer but more difficult 
distinctions of the following group from the above statistical table • 

Symptomatic depressions. 

Depressive hallucinoses. 

Involution melancholia. 

Depressions undifferentiated. 

Manic-depressive. 

Allied to manic-depressive. 



MENTAL DISEASES. 

Since this book was first published there has been much change in 
the views of the psychiatric world. The immense strides in general 
medical science have had their influence also in this department of medi- 
cine. There has been accumulated a vast amount of clinical material, 
much more thoroughly studied than ever before. Our knowledge of 
clinical forms and phases, of course and outcome, of neuropathology, 
and of psychology has been enormously advanced. In each new edition 
of this volume some changes commensurate with this progress have been 
made, and in this particular edition the classification is radically re- 
arranged in conformity with present-day judgment ; at the same time 
the needs of the student and practitioner are chiefly considered, since 
the book is written for them and not for the specialist. 

Since the alcoholic and other toxic psychoses and the infection- 
exhaustion psychoses are described under special headings in the chapter 
on General Etiology, only the following most important types of insanity 
will be treated in separate chapters : 

1. Manic-depressive insanity. 

a. Manic phase. 

b. Depressive phase. 

c. Circular insanity. 

d. Involution melancholia. 

2. Dementia prsecox. 

3. Senile dementia and other senile pyschoses. 

4. General paresis. 

5. Paranoia. 

6. Neuropsychoses, hysterical insanity, epileptic insanity. 

7. Idiocy, imbecility, and feeble-mindedness. 



GENERAL ETIOLOGY OF INSANITY. 689 

CHAPTER II. 
GENERAL ETIOLOGY OF INSANITY. 

The proportion of the insane to normal individuals may be stated 
to be about 1 to 300 of the population, though this proportion varies 
somewhat within narrow limits among different races and countries. It 
is probable that the intemperate use of alcohol and drugs, the spread- 
ing of syphilis, and the overstimulation in many directions of modern 
civilization have determined an increase difficult to estimate, but never- 
theless palpable, of insanity in the present century as compared with 
past centuries. 

The amount of such increase might easily seem to be large, on super- 
ficial examination, because of the imperfection of census-taking in the 
past, the accumulation of the chronic insane, and in new communities 
the constant upbuilding of new asylums. 

Sex. — As regards sex, women and men are about equally affected, 
for the particular etiological factors determining insanity in the one 
(such as the puerperal period, the menopause, etc.) are evenly balanced 
by the special causes acting upon the other (struggle for existence, 
drunkenness, syphilis, etc.), and both sexes are about alike in their sus- 
ceptibility to the two great etiological elements in alienation of the mind 
— heredity and mental or bodily strain. 

Age. — The question of age is of great importance in a study of the 
etiology of insanity. "While individuals are liable to mental aberration 
at any age, yet there are particular periods of life characterized by 
special vulnerability. In general, it may be said that this vulnerability 
is greatest in women between the ages of twenty-five and thirty-five, 
and in men between twenty and fifty, for it is at middle age that we 
find the maximum accumulation of etiological factors. But there are 
physiological epochs that influence markedly the line of psychic mor- 
bidity, and these are the periods of puberty and adolescence (fourteen to 
twenty years), that of genital involution in women (forty-five), and that 
of senile involution (sixty to seventy years). 

But the chief factors in the causation of insanity may be summed up 
in two words — heredity and strain. The former is responsible for in^ 
stability of the nervous system, the latter is multiform in character, 
comprising all of the stresses, physical and mental, direct and indirect, 
autochthonous and environmental, which may undermine the nervous 
constitution and bring it to its point of collapse. 

Heredity. — In determining the factor of heredity we must not be 
content with ascertaining the existence of psychoses in the ascendants, 
but must seek, by careful interrogation of various members of the family, 
for some of the hereditary equivalents, such as epilepsy, chorea, hys- 
teria, neurasthenia, somnambulism, migraine, organic diseases of the 
central nervons system, criminal tendencies, eccentricities of character, 
drunkenness, etc., for these equivalents are interchangeable from one 



690 MENTAL DISEASES. 

generation to another, and are simply evidences of instability of 
the nervous system. It is the unstable nervous organization that 
is inherited, not a particular neurosis or psychosis, and it must be 
our aim in the investigation of the progenitors to discover the evidence 
of this. 

That the statistics of insanity as regards heredity are often faultily 
gathered is too well known. In the first place, the recorder of the 
history of a patient frequently neglects to extend his inquiry far enough 
to include all of the transmissible psychoneuroses, and, in the second, the 
relatives are prone to conceal any supposed hereditary taint in the 
family. Here, for example, is a table prepared by the Lunacy Commis- 
sioners, showing the causes of insanity in 136,478 admissions to asylums 
in England and Wales, in which I find the item " hereditary influence 
ascertained " 2*0.5 per cent. Surely, so small a figure does not represent 
the true proportion of heredity as an etiological factor ! 

It will take many decads of much more careful compilation of his- 
tories to establish the actual ratio, but we shall attain nearer to the facts 
year by year. 

No one has better formulated the principles of heredity in relation 
to insanity than Mercier, 1 who points out, among other things, that, 
besides the importance of the direct transmission of an unstable nervous 
system, there is another law of heredity, which is known as the law of 
sanguinity. Two parents may be perfectly stable and have normal organ- 
isms, and yet produce offspring with unstable and abnormal nervous 
constitutions, because of the unsuitability of the sexual elements of the 
parents to each other. The perfect organization of the progeny is the 
result of three factors — the quality of the germ (which brings matter), 
the quality of the sperm (which brings force), and the suitability of the 
one to the other. 

The laws of heredity as they relate to insanity may be summarized 
briefly as follows : 

1. The child tends to inherit every attribute of both parents. 

2. Contradictory attributes can not be inherited from both parents. 

3. The child may inherit the attributes of either parent solely. 

4. It may inherit the qualities of one parent in some respects and 
of the other in other respects. 

5. It may inherit the father's attributes for one period of existence 
and the mother's for another. 

6. Some attributes have the quality of prepotency, or the tendency 
to push aside or overrule other attributes. 

7. Attributes which are similar in both parents tend to become pre- 
potent, giving rise to convergent or cumulative heredity. 

8. Attributes may be transmitted in latent form from one genera- 
tion to another, to reappear in a third or fourth or still more remote 
generation — a phenomenon termed " reversion." 

9. Attributes tend to appear in the progeny about the same time of 
life at which they became manifest in the parents. 

1 " Sanity and Insanity." 



GENERAL ETIOLOGY OF INSANITY. 691 

10. Attributes of the father tend to be inherited by the sons and of 
the mother by the daughters. 

A study of the above laws will explain many of the puzzling 
features of psychopathic heredity, — why, for instance often only a few of 
the children of a neurotic parent suffer from neuroses or psychoses, and 
why psych oneuroses may develop in the progeny of healthy parents 
(latency). It must be remembered, too, that there is a variation in the 
degree of hereditary taint originated by the several heritable equiva- 
lents. Thus, simple neurasthenia, eccentricity of character, and a puer- 
peral or senile psychosis are not so serious a heritage as epilepsy, 
chronic alcoholism, paranoia, and imbecility. The taint in a family is 
greater the larger the number of members and branches afflicted. 
When the degree of hereditary taint is marked, the psychoses which 
may develop tend to be modified from the ordinary types of such psy- 
choses, and this deviation is termed hereditary degenerative modifica- 
tion, — or, in short, hereditary degeneracy, — while the insanity evolved is 
designated as a degenerative psychosis. The particular degenerative 
psychoses are such forms as idiocy, imbecility, feeble-mindedness, peri- 
odical and circular insanity, hysterical insanity, acute simple paranoia, 
polymorphic insanity, etc. A polymorphic course is particularly char- 
acteristic of psychic degeneracy, so that sometimes a perfect chain of 
psychopathic conditions and psychoses will be manifested throughout 
the life of the degenerate. 

The polymorphism of hereditary transmission sometimes manifests 
itself in what is known as progressive hereditary degeneracy. For 
example, drunkenness in one generation may lead to simple psychoses 
in the next, to complex degenerative psychoses, epilepsy, etc., in the 
third generation, and finally, in the fourth, to idiocy, sterility, and the 
annihilation of the stock. 

It is only lately that the laws of heredity, as they relate to in- 
sanity, have begun to be studied in the light of the new theories 
of Mendel and others. The results of observations of plants have 
certainly revealed some remarkable facts, but how far these can be 
applied to the infinitely complex conditions of the human organism 
and human society remains to be determined by years of most careful 
investigation. 

The indications of degeneracy in an individual are termed the stig- 
mata of degeneration, or stigmata hereditatis. They may be defined as 
anatomical or functional deviations from the normal, which in them- 
selves are usually of little importance as regards the existence of an 
organism, but are characteristic of a marked or latent neuropathic dis- 
position. Much study has of late years been devoted to these indices 
by many investigators, particularly in their relation to insanity, idiocy, 
and criminal anthropology, and it behooves all who have to do with the 
development and care of the human body in any particular — and this 
refers especially to men of the medical and allied professions — to 
familiarize themselves with these signs of degeneration, in so far as they 
concern their own special provinces of work. These stigmata are vices 



692 MENTAL DISEASES. 

of functional and organic evolution. The deviations from the normal 
may be in the way of excesses or arrest of development. They must 
be distinguished from the deficiencies or deformities produced by acci- 
dents at birth or by disease. I have said that these stigmata are ana- 
tomical and functional, but it is more convenient to divide the func- 
tional group into physiological and psychic classes. It is the latter 
which we are more apt to observe in our social relations with degenerate 
individuals. The psychic stigmata are always characterized by want 
of balance or lack of proportion between certain undeveloped or exces- 
sively developed faculties and other faculties which are normal. De- 
fect of moral sense, of attention, of memory, will, judgment, or unbal- 
anced excess of musical or mathematical aptitudes may be cited as 
instances of psychic stigmata. Hence the three following divisions 
may be made of all the degenerative indices : (1) Anatomical stigmata ; 
(2) physiological stigmata ; (3) psychic stigmata. 

Anatomical Stigmata. 
Cranial anomalies. 
Facial asymmetry. 
Deformities of the palate. 
Dental anomalies. 
Anomalies of the tongue and lips. 
Anomalies of the nose. 
Anomalies of the eye : # 

Flecks on the iris ; strabismus ; chromatic asymmetry of the iris ; 
narrow palpebral fissures. 

Albinism. 

Congenital cataracts. 

Microphthalmos. 

Pigmentary retinitis. 

Muscular insufficiency. 
Anomalies of the ear. 
Anomalies of the limbs : 

Polydactyly. 

Syndactyly. 

Ectrodactyly. 

Symelus. 

Ectromelus. 

Phocomelus. 

Excessive length of the arms. 
Anomalies of the body in general : 

Herniae. 

Malformation of the breasts, thorax» 

Dwarfishness. 

Giantism. 

Infantilism. 

Feminism. 

Masculinism. 

Spina bifida. 
Anomalies of the genital organs. 
Anomalies of the skin. 

Polysarcia. 

Hypertrichosis. 

Absence of hair. 

Premature grayness. 



GENERAL ETIOLOGY OF INSANITY. 593 

Physiological Stigmata. 

Anomalies of motor function : 

Retardation of learning to walk. 

Tics. 

Tremors. 

Epilepsy. 

Nystagmus. 
Anomalies of sensory function : 

Deaf-mutism. 

Neuralgia. 

Migraine. 

Hyperesthesia. 

Anesthesia. 

Blindness. 

Myopia. 

Hypermetropia. 

Astigmatism. 

Daltonism. 

Hemeralopia. 

Concentric limitation of the visual field. 
Anomalies of speech : 

Mutism. 

Defective speech. 

Stammering. 

Stuttering. 
Anomalies of genito urinary function : 

Sexual irritability. 

Impotence. 

Sterility. 

Urinary incontinence. 
Anomalies of instinct or appetite : 

Uncontrollable appetite (food, liquor, drags). 

Merycism. 
Diminished resistance against external influences and diseases. 
Retardation of puberty. 

Psychic Stigmata. 
Insanity. 
Idiocy. 
Imbecility. 
Feeble-mindedness. 
Pavor nocturnus. 

Precocity ; one-sided talents ; disequilibration. 
Eccentricity. 
Moral delinquency. 
Sexual perversion. 

Having made this attempt to classify the various stigmata, we may 
now proceed to examine them in some detail : 

Cranial Anomalies. — The most important features to be noted in 
connection with the head are asymmetry and a variety of deformities. 
It is necessary to an understanding of these stigmata to go over briefly 
a few facts of craniometry and cephalometry. 

A score or more of distinguished anthropologists of the present cen- 
tury have been trying to discover racial distinction in human skulls ; 
but the fact is that there are not so many characteristics of race in the 
cranium as in other parts of the body, and, accordingly, there are still 
wide differences of opinion as regards a scientific craniological classifi- 
cation. Races have been mingling so many thousands of years that 



694 MENTAL DISEASES. 

cranial dissimilarities are the rule among them, even in tribes, and to 
some extent in families. These diversities of form have been designated 
as dolichocephalic, mesocephalic, and brachycephalic — words which 
merely convey an idea of the relation of the length to the breadth of 
the skull when viewed from above. The anteroposterior is to the 
biparietal diameter as 100 is to x, is the formula for determining this 
" cephalic index." All length-breadth indices below 78 are considered 
dolichocephalic ; from 78 to 80, mesocephalic; and above 80, brachy- 
cephalic. We may assume that the physiological limits of this index 
are 70 to 90. This is based upon thousands of measurements of skulls 




Fig. 269. 

by various investigators. Any excess or diminution of these figures 
must hence be regarded as pathological (Fig. 269). 

But while one skull may be narrower or broader than another, there 
is compensation in other diameters. The dolichocephalic has a greater 
vertical diameter, for instance, than the brachycephalic skull. 

Besides these characteristics, something must be said regarding the 
physiological asymmetry of the skull. The fact that the arms and hands 
are not symmetrical on the two sides of the body, either in size or func- 
tion ; that the legs and feet are not symmetrical ; that the left cerebral 
hemisphere is larger and more complicated than the right, would natu- 
rally lead us to anticipate some slight asymmetry of the two sides of the 
skull, and the facts of observation support us in the statement that asym- 
metry is the rule and perfect symmetry the exception. More than a 
thousand postmortem examinations, the examination of several hundred 
heads, and an inspection of some collections of skulls, such as that of 
Blumenbach, where I have particularly noted this point, together with 
the testimony of others, justify me in this assumption. 

Asymmetry sometimes reaches extraordinary proportions, — often with 
quite a normal state of brain function, often with marked psychopathic 
changes. Outside of purely physiological asymmetry, we have that 
depending upon defective development and disease. One of the first of 
nature's constructive principles in fashioning the skull is the struggle 
of its contents for volume. Hence, as long ago pointed out by Yir- 
chow, premature synostosis of any cranial suture will lead to compen- 



GENERAL ETIOLOGY OF INSANITY. 695 

satory deformity. So, too, will arrest of developmen in any center of 




Fig. 270.— Chemocephalus. 

ossification, or a unilateral aplasia or hyperplasia of the skull bones, or 
of the contents of the skull. 

Aside from the deformities of the head which are congenital in char- 
acter, the diseases which most commonly produce cephalic deformation 
in early life are rachitis and hydrocephalus; in later life, tumors, exos- 
toses, etc.; while at all periods of life the shape of the skull is menaced 
by injuries, from a forceps delivery to a falling brick. The following 
are some of the commoner designations of well-known cranial deformi- 
ties: 

Chemocephalus is flat-headedness. In this there is flatness at the 





Fig. 271. — Leptocephalus. 



top of the head. The condition is also called platicephalus (Fig. 
270). 

Leptocephalus. — Early synostosis of the frontal and sphenoid pro- 
duces leptocephalus, or narrow-headedness (Fig. 271). 

Macrocephalus is a large head, usually due to hydrocephalus. 

Microcephalus is a small head, due either to aplasia of the brain or 
premature synostosis of the sutures (rarely the latter). 

Oxycephalus, or steeple-shaped skull, is due to synostosis of the 
parietal with the occipital and temporal bones, with compensatory de- 
velopment in the region of the bregma. Another name for this is acro- 
cephalus (Fig. 272). 

Plagiocephalus, or oblique deformity of the head, is due to uni- 
lateral synostosis of the frontal with one of the parietal bones (Fig. 
273). 



696 



MENTAL DISEASES. 



Scaphocephaly is probably caused either by too early union of 
the sagittal suture or by the development of both parietal bones from 
one center. The top of the head is keel-shaped (Fig. 274). 




Fig. 272. — Oxycephalies. 



Fig. 273. — Plagiocepbalus. 



Trigonocephalus. — Premature union of the frontal suture, resulting 
in very narrow forehead and great width behind, giving rise to the term 
trigonocephalus (Fig. 275). 

The two systems of measurement — the craniometrical and the ceph- 
alometrical — differ but slightly from each other, the former, of course, 
being the more exact, since every portion of the naked skull is attain- 
able. 

I would recommend the following series of measurements to be 




Fig. 274. — Scaphocephalies. 



Fig. 275. — Trigonocephalus. 



taken — eleven in number — in order to form a just idea of the capacity, 
shape, and symmetry of any head (Figs. 276 and 277) : (1) The circum- 
ference ; (2) the naso-occipital arc (N to T) ; (3) the nasobregmatic arc 
[N to /?) ; (4) the bregmatolambdoid arc (/5 to A) ; (5) the binauricular 
arc ; (6) the anteroposterior diameter ($ to 0) ; (7) the greatest trans- 
verse diameter (length-breadth index) ; (8) the binauricular diameter ; 
(9) the two auriculobregmatic radii; (10) the facial length; (11) the 
empirical greatest height (B to t 3). 

In addition to acquiring these mathematical data, cephaloscopic 



GENERAL ETIOLOGY OF INSANITY. 



697 



drawings are invaluable as exhibiting deformity clearly to the eye. 
Hence, the horizontal circumference, naso-occipital curve, and binau- 
ricular curve should be taken with a strip of lead, or, what is better, 
with the instrument devised by Luys (on the principle of the hatter's 
conformateursj, and the curves projected on paper. 

Dolichocephalic heads, as a rule, have narrow, and brachycephalic 
have broad, faces. Something should here be said concerning prog- 
nathism, of which there are several forms. The best method of deter- 
mining it is to measure the angle made by a line drawn from the nasal 
root to the junction of the inferior nasal spine and alveolar process 
(Fig. 277, Xto x) with a vertical line dropped from the nasal root to 
Broca's horizontal. It is found that every normal skull exhibits this 
subnasal prognathism, but there is a wide variation in degree. Extra- 
ordinary prognathism, orthognathism, and opisthognathism — meaning 
extreme projection, straightness, or inclination backward of the sub- 
nasal line — are pathological. 

The empirical greatest height of the head is an approximate measure- 



^gjCUl/i 




3 1 NAUR /C (/LA R- D/AM 
Fig. 276. 




Fig. 277. 



ment of the distance between the basion and vertex of the skull (jB 
to P } or U). A line from the external occipital protuberance to the 
lowest median point of the superior maxilla, just above the incisors (T 
to 31), passes almost directly through the basion. Hence, in cephal- 
ometry, by taking this diameter and the radii from each extremity to 
the bregma, we have a triangle (J/, P, T) whose height (i>, /?) is easily 
ascertained. The height averages 13.3 cm. in men, 12.3 in women, 
and the physiological variation is from 11.5 to 15. 

The only instruments necessary for obtaining the data just described 
are a pair of calipers, the tape-line, and a strip of sheet-lead two feet 
long by \ or § of an inch wide. Benedikt's calipers (manufactured 
by Wolters in Vienna), which are here illustrated, are to be recom- 
mended for their exactness (Fig. 278), as are also those that I have had 
made for my own use (Fig. 279). 

Excessive prognathism is found among criminals, in microcephali, 
and in cases of hemi- and paraplegia spastica infantilis. Skulls known 
as crania progenaea have considerable pathological significance. In 
these, lower teeth project beyond the upper, and the inferior maxillary 



698 



MENTAL DISEASES. 



angle is obtuse, due, probably, to aplasia of the upper or hyperplasia 
of the lower maxilla.. 

The demonstration of the empirical greatest height is often quite 
valuable as an index of degenerative and neuropathic types. The 
following are some general points which should be considered in the 
examination of these cases : 

A skull below the normal type in volume belongs to an abnormal 
individual. 

Undertypical measurements of the head should always lead us to 
entertain the suspicion of defective cerebration. 

Abnormal smallness of any part of the skull permits the conclusion 
that the part of the brain in its neighborhood is imperfectly developed. 

Excessive development of the head has a double signification. It is 




MAAMMAMA 




-r.r.T.T.r.T.r.^T.T.r i 



Fig. 278.— Benedikt's 
calipers. 



Fig. 279.— Author's calipers. 



always pathological, but may mean abnormality of brain or successful 
compeusation. "Wormian bones are also doubly significant. They 
either represent a pathological process or a successful effort of nature 
in repair. 

Hemiplegia spastica infantilis, epilepsy, and intellectual or ethic 
weakness often exhibit unilateral aplasia of the skull. 

The skull is representative of the brain only during the years of its 
development, and it must be remembered that psychopathic deteriora- 
tion often has its inception subsequent to the completion of the process, 
when no impression can be made upon its bony walls. 

I have prepared a table of the measurements recommended, showing 
the averages in adults, male and female, together with the physiological 
variation, excesses above or below which are significant of morbidity. 
It is based upon the examination of some hundreds of skulls and 
heads, and upon statistics given by various authorities who have made 
especial study of this department of anthropometry. Hence it may 
be depended upon as a fair estimate of the dimensions of the head in 
most of the Caucasian races. The table is as follows : 



GENERAL ETIOLOGY OF INSANITY. 
Table of Craniometrical Measurements. 



699 





Average in 

Adult in 

Centimeters. 


* & 

° 2 

?23 
w ^ 






Is 


B2 

s 


Remarks. 


1. Circumference, 


52 


50 


48.5-57.4 


Roughly approximated, the 
volume is to the circum- 


2. Volume, 


1500 


1300 


1201-1751 


ference as 1350 c.c. is to 
50 cm. 


3. Naso-occipital arc, .... 


32 


31 


28-38 


In figure, iVto T. 


4. Nasobregmatic arc, . . 


12.5 


12 


10.9-14.9 


Nto(3. 


5. Bregmatolambdoid arc, 


12.5 


11.9 


9.1-14.4 


13 to A. 


6. Binauricular arc, ... 


32 


31 


28.4-35 




7. Anteroposterior diameter, 


17.7 


17.2 


16.5-19 jStoO. 


8. Greatest transverse diameter 


14.6 


14 


13-16.5 


The formula for the length- 
breadth index is : 

Length : Breadth : : 100 : x. 

An index below 78 is doli- 
chocephalic ; 78 to 80, 
mesocephalic ; above 80, 
brachycephalic. 


9. Length-breadth index, . . 


82.2 


83.8 


76.1-87 


10. Binauricular diameter, . . 


12.4 


11.9 


10.9-13.9 


B The height 

A B-X of the 

/ ! \ . triangle E, 

/ \ \ B, E formed 

F/ • \/rby thft anri- 


11. Auriculobregmatic radii, . 








A culobregma- 
tic radii and the binauri- 
cular diameter, averages 
11.17 with a variation 
from 10 to 12.65. 


12. Facial leugth, 


12.37 


— 


10.5-14.4 


From root of nose, JV, to 
lowest part of chin. 


13. Empirical greatest height, 


13.3 


12.3 


11.5-15 


The empirical greatest 
height, B, /?, is obtained 
by measuring the sides of 
the triangle M,/3,T. 



These measurements are those of the adult human skull. As the hair and scalp 
superadd about 3 cm., about 6 per cent, should be deducted in the head measurements 
Nos. 1, 3, and 6 to obtain those of the skull. In taking the diameters Nos. 7 and 8, 
deduct 1 cm. (the scalp averaging 5 mm. in thickness), and from the shorter radii, such 
as Nos. 10 and 11, subtract but 7 mm. 

Facial Asymmetry.— Inequality of the two sides of the face — 
when congenital and not due to some such disease as hemiatrophy — is 
to be looked upon as a stigma of degeneration. In the same category 
may be grouped various irregularities, and such conditions as excessive 
prognathism or retrognathism. Great prominence or unequal promi- 



700 



MENTAL DISEASES. 



nence of the malar bones is to be observed, and also asymmetry of the 
orbits (Fig. 280). 

Deformities of the Palate. — In connection with the soft palate, 
bifurcation of the uvula may be mentioned. As regards the hard 
palate, I have dwelt upon its deformities at some length in an article in 
the "International Dental Journal" (December, 1895), and the facts 
there brought forward may be recapitulated as follows : 

While the palate occupies but a small place in this great category of 
hereditary stigmata of all kinds, it is one of the anatomical group, and 
this group is for many reasons the one of greatest importance. In this 




Fig. 280.— Male epileptic, aged forty years, with glabrous face and chin and facial asymmetry. 



group, too, it occupies a distinctive place as being among the most 
striking, frequent, and significant of the anomalies. 

The arch of the hard palate presents considerable variation within 
strictly normal anatomical limits. A large, wide, moderately high 
vault is what may be called a normal standard. It means the highest 
evolution, judging from the fact that the mouth-cavity increases in 
capacity as we ascend the vertebrate series. Deviations from that 
standard are not at all infrequent, and yet such deviations may be nor- 
mal. Thus, the palate may be low and broad, or it may be high and 
narrow ; it may be short or long in its anteroposterior diameter ; it 
may be ridged unduly along the palatine sutures, or it may present 
marked rugosities on its surface, especially in the anterior region ; yet 
these variations are normal. Probably we may look upon these pecu- 



GENERAL ETIOLOGY OF INSANITY. 701 

liaritles as a species of compensatory development. Just as in a study 
of heads we find some very long and low, and others short and round 
and high, and recognize the fact that the shortness in one dimension is 
compensated for by a corresponding increase in another, so we may 
regard variation in palatine diameters. 

The pathological palate has not been studied as much as it deserves 
to be. Save occasional and casual references to the " Gothic " palate 
in literature, and one or two papers upon the "torus palatums," very 
little has been written upon the subject. In my paper, previously referred 
to, I have attempted to classify such pathological palates as could be justly 
looked upon as indicative of degeneracy. The word Gothic having been 
so long in use, and the hard palate being much like an arch or roof, 1 I 
have followed architectural nomenclature in the classification offered. 

Pathological Palates : 

1. Palate with Gothic arch (Fig. 281). 

2. Palate with horseshoe arch (Fig. 282). 

3. The dome-shaped palate (Fig. 283). 

4. The flat-roofed palate (Fig. 284). 

5. The hip-roofed palate (Fig. 285). 

6. The asymmetrical palate (Fig. 286). 

7. The torus palatinus (Fig. 287). 

The seven varieties named are to be looked upon as types merely. 
Each type will be found to present variations and combinations with 
other forms. Thus, the Gothic arch may have a low or high pitch and 
be short or long. The horseshoe arch (a familiar one in Moorish archi- 
tecture) is always easily distinguished, but, owing to its conformation, 
a cast can not well be taken of it to show it in a perfect outline. The 
dome-shaped palate may be high or low, may be combined with asym- 
metry or torus. The presence of a torus in the Gothic variety is apt to 
destroy the purely Gothic form, and may cause it to resemble the flat- 
roofed palate. Under the heading of flat-roofed palate I should include 
all such palates as are nearly horizontal in outline, as well as those with 
inclined-roof sides but flattened gable. In the hip-roofed palate we 
have the sloping sides as usual, but also a marked pitch of the palate 
roof in front and behind ; occasionally one may meet with a palate of 
this kind with so remarkable a pitch from before backward that it is 
almost like a Gothic roof turned about so that the gable runs trans- 
versely. 

Asymmetry in the palate is commonly observed in many of the 
previously described forms, but occasionally is the only noteworthy 
peculiarity. It is usual to find asymmetry of the face and skull in 
cases with an asymmetrical palate. The torus palatinus (Latin torus, 
swelling) was first mentioned by Chassaignac as a mediopalatine exos- 
tosis. It is a projecting ridge or swelling along the palatine suture, 
sometimes in its whole length, sometimes in only a portion of its course. 
It is always congenital. It varies considerably in its shape and size, so 

1 " There is some confusion in literature of the roof of the mouth, or hard palate, 
referred to in this paper, with the dental arch, which is quite another thing." 



702 



MENTAL DISEASES. 



that as many as five or six different species of torus are recognized. It 
may be wedge-shaped, narrow, broad, very prominent, or irregular. I 
have said nothing about cleft-palate, for I am not sure that it may be 




Fig. 281.— Palate with Gothic arch. 




Fig. 282.— Palate with horseshoe arch. 



classed among the well-marked stigmata of degeneration. I have 
found but two or three cleft-palates among the 450 idiots and imbeciles 
on Randall's Island, while a number of cases of this kind with which I 



GENERAL ETIOLOGY OF INSANITY. 703 

have come in contact in my professional life were very far from degen- 
erates. However, it would seem that there is great need of a faithful 
study of a large number of cases of cleft-palate in relation to the ques- 




Fig. 283.— The dome-shaped palate. 




Fig. 284.— The flat-roofed palate. 



tion of degeneracy. The deformed palate is, to my mind, one of the 
chief anatomical stigmata of degeneration. 

It is true that, from this single indication, it would not be strictly 



704 



MENTAL DISEASES. 



scientific to adjudge an individual a degenerate. Occasionally, perhaps, 
a case presents itself where this anatomical stigma alone would suffice 
to insure a diagnosis of this nature ; but usually other stigmata coexist, 
such as cranial anomalies, deformities of the ear, and the like. The 




Fig. 285.— The hip-roofed palate. 




Fig. 286.— The asymmetrical palate. 



frequency of the pathological palate among marked degenerates, such as 
the insane, idiots, and epileptics, has been testified to by many investi- 
gators. Thus, Talbot reported 43 per cent, of abnormal palates in 
1605 inmates in institutions for the feeble-minded. Ireland makes 
it nearer 50 per cent. Charon, a later writer than these, found abnor- 



GENERAL ETIOLOGY OF IX S AX IT Y. 705 

roal palates in 10 per cent, of apparently norma] persons, in 82 per 
cent, of idiots and feeble-minded, in 76 per cent, of epileptics, in 80 per 
cent, of cases of insanity in general, in 70 per cent, of the hysterical 
insane, and in 35 per cent, of cases of general paralysis. Xiieke has 
studied particularly the torus palatums in 1449 individuals, normal and 
psychopathic; he found it present in 23.9 per cent, of psychopathic 
women (insane, epileptic, idiot, and criminal), 32.9 per cent, of epilep- 
tic women. 34.4 per cent, of criminal women, 22.7 per cent, of normal 
women. The percentages were smaller in men than in women. A 
narrow torus is more common than a broad one. 

• Stieda examined 1500 skulls for the torus from an anthropological 
point of view. The skulls were of Prussians. Armenians. Africans, 
Frenchmen, Russians, and Asiatics. He decided that it lias no anthro- 
pological significance ; gives no racial distinction. While the torus is 




Fig. 287. — Torus palatinus (broad, wide torus). 

undoubtedly of value as an index of degeneration, particularly where it 
is well marked, it probably has less importance in this respect than 
some of the other forms of pathological palate. 

Dental Anomalies. — Among anomalies of the teeth are macro- 
dontism, microdontism, projecting teeth, badly placed or misplaced 
teeth, double row of teeth, or teeth which are striated transversely or 
longitudinally. Caries of the teeth and Hutchinson's teeth are due to 
neglect or disease. The latter, however, may often be considered as a 
stigma of degeneration. Then there is a retardation of the first and 
second dentition. 

Anomalies of the Tongue and Lips. — A very large tongue 

macroglossus) is not infrequently observed among the lowest classes of 

degenerates, as in idiocy. Sometimes there is microglossus. asymmetry 

of the two halves, or bihdity of the point. Harelip is somewhat more 

common than cleft-palate, but. like the latter, its exact standing as a 

45 



706 MENTAL DISEASES. 

degenerative stigma is not fully determined. Undue swelling or 
puffiness of the lips is noteworthy. 

Anomalies of the Nose. — Marked deviation of the nose to one 
side or the other should be noted. Taken alone it may possess little 
significance, but in conjunction with other stigmata it is of value. The 
nose may be absent, or present defect of osseous development (nasus 
aduncus) or atresia of the nasal fossae. 

Anomalies of the Eye. — The pathological conditions of the eye 
have been placed in two groups in the foregoing classification, since some 
are anatomical and some physiological. To enumerate them altogether, 
they are as follows : 

Anatomical. Physiological. 

Flecks on the iris. Blindness. 

Strabismus. Myopia. 

Chromatic asymmetry of the iris. Hypermetropia. 

Narrow palpebral fissures. Astigmatism. 

Albinism. Daltonism. 

Congenital cataracts. Hemeralopia. 

Pigmentary retinitis. Concentric limitation of the visual field. 

Microphthalmos. Nystagmus. 

Muscular insufficiency. 

It is true that any one or two or more of these conditions present do 
not certainly indicate degeneracy, but they are significant in connection 
with other abnormal states, and all of them are more frequently 
observed in degenerate individuals, especially the lower orders, than in 
normal persons. In idiots, convergent strabismus, due to defect of 
refraction and in conjunction with hypermetropia, is very common. 
Muscular insufficiency and nystagmus (lateral or rotatory) are also often 
met with in this class of cases. In paralytic and other idiots and imbe- 
ciles homonymous hemianopsia is sometimes met with. 

Anomalies of the Ear. — Deformities of the ear have been de- 
servedly well studied, for as stigmata of degeneration they take high 
rank, like anomalies of the hard palate, in the anatomical group. 
Morel, Stahl, Wildermuth, Binder, and, more recently, Schwalbe, have 
given us especially good studies of these conditions. From their 
writings and my own studies, the following classification (following 
Binder) into twenty-two varieties may be made : 

I. Abnormally implanted ears ; they project too far or lie too 
closely, are placed too high or too low, too far forward or too far 
backward on the head. 

II. Excessively large ears : (1) absolutely too large ; (2) rela- 
tively too large in small or microcephalic individuals. 

III. Ears which are too small. 

IV. Too marked conchoidal shape of the ear. The details of the 
ear (anthelix and crura, etc.) are but slightly marked, while the helix 
outlines the ear like the rim of a funnel. 

V. Ears which have a general ugly shape. The breadth of the 
upper part may exceed that of the lower, and vice versa ; excessive 
length ; ears without lobules ; unusually short ears. 



GENERAL ETIOLOGY OF INSANITY. 



707 



VI. Ear not uniform in width ; usually a long ear with one 
or more constrictions in its breadth. 

VII. The Blainville ear ; asymmetry of various kinds of the 
two ears. In most cases the asymmetry is due to an anomaly of the 
left ear. 



Fossa ovalis 



Fossa cymbse 



Fossa concha 



Incisura intertragica 




Fig. 288— Normal ear. 



Fossa scapkoidea 



VIII. The ear without lobule ; there are usually other deformities 
of this ear besides the absence of lobule, such as too large a concha, 
prominence of the anthelix, etc. 

IX. The ear with adherent lobule ; the lobule is enlarged, ad- 
herent, and inclines downward toward the cheek. 





Fig. 289. — Blainville ear ; also excessive length 
of ears. 



Fig. 290.— Morel ears. 



X. The Stahl ear, Xo. I. 1 A series of anomalies of the helix. 
The helix is broad, like a band, and coalesces with the cartilages 



1 See " Zeitschrift f iir Psych.," vol. xvi. 



708 



MENTAL DISEASES. 



of the crura furcata. The fossa ovalis and fossa scaphoidea are 
scarcely to be seen. The lower half of the helix is obliterated. There 
are occasionally slight variations from this type. 

XL The Darwin ear ; helix interrupted where its transverse 
portion passes into the descending, and at this point is a projection of 
the rim above and outward, like the pointed ear of lower animals. 

XII. The Wildermuth ear. 1 The anthelix projects so far as 
to form the most prominent part of the auricle. 

XIII. The ear without anthelix or crura furcata. 

XIV. The Stahl ear, Xo. 2. Multiplication of the divisions of 
the crura furcata, so that there are three instead of two crura. 

XV. Wildermuth' s Aztec ear. Lobule wanting ; the whole 
ear seems pushed forward and downward ; the cms superius of the 
anthelix coalesces with the helix, while its crus anterius is scarcely 
perceptible. 

XVI. The Stahl ear, Xo. 3. Only the crus anterius of the crura 
furcata is present, while the auricle seems divided into two halves by a 
ridge from the antitragus. 

XVII. The ear with double helix. 





Fig. 291.— Stahl ear, No. 1. 



Fig. 292.— Darwin ear. 



XVIII. The ear with too large or too small a concha. 

XIX. The ear with continuous fossa scaphoidea. The fossa 
passes down into the lobe. 

XX. The Morel ear. A form marked by abnormal develop- 
ment of the helix, anthelix, fossa scaphoidea, and crura furcata, so that 
the folds of the ear seem obliterated, and the ear is smooth, larger than 
usual, often prominent, and with thin edge. 

XXI. Ears misshapen by abnormal cartilage development. 
Here belong all irregular cartilaginous growths and thickenings except 
those caused by hematoma of the ear. 

XXII. Various peculiarities, difficult to classify, are included 
here, such as abnormalities of the semilunar incisure of the tragus and of 
the meatus, coloboma of the lobule, hairiness of the different parts of 
the auricle, accessorv ears, clefts, etc. 



"Wurt. Corresp.-Blatt," 1886, No. 40. 



GENERAL ETIOLOGY OF INSANITY. 



709 



The most important malformations of the ear — those that may be 
regarded as belonging to the stigmata of degeneration, and those, too, 
which are striking and plain to the eye — are to be summarized as 
follows : 

The deep position of the crus anterius. 

Marked prominence of the anthelix. 

Excessive broadening of the ear. 

Stunted development of or absence of the helix. 

Trifurcation of the anthelix. 

Widening of the fossa scaphoidea. 

Absence of the eras superius. 

Complete absence of lobule. 

Asymmetry of the two ears. 

Excessive enlargement or diminution of the concha. 

Excessive conchoidal structure of the ear. 

Reference is occasionally made in literature to the Cagot ear. The 
Cagot is a species of cretin in the French and Spanish Pyrenees, in 
which one of the chief physical deformities is absence of the lobule of 
the ear. 

Binder states that the adherent lobule exists in almost one-third of 
normal persons, and in the photographs of several hundred distinguished 
persons 15 per cent, had abnormal lobules. At the same time more 




Fig. 293.— Excessive length of ears; facial asymmetry. 



than twice as many adherent lobules are found in degenerates as in 
normal individuals. 

Now, with regard to statistics of malformed ears in degenerate in- 
dividuals, Wildermuth noted this condition in 41 per cent, of 142 idiots. 
Binder found 64 per cent, of degenerate ears in 354 insane persons. 
It is to be remarked, however, that Binder was more careful in his ex- 
aminations, and by long practice had acquired more expert knowledge 
than Wildermuth. Frankel observed degenerate ears in 29 cases out 
of 32 with cranium proganseum. 

Knecht found 20 per cent, of degenerate ears among 1274 criminals, 
27 per cent, among 48 epileptics, and 32 per cent, among 84 insane. 



710 



MENTAL DISEASES. 



Binder noted degenerate ears 



in 33 persons outside of institutions, 
supposed to be normal individuals. Inquiring closely into their his- 
tories, he discovered that 7 of them had insane parents, brethren, or 
children ; in 1 9 there were decided psychic abnormalities, and only 7 





Fig. 294. — Broad, baud-like helix ; no ant- 
helix ; no lobule ; excessive size of fossa cym- 
bse. 



Fig. 295. — Excessive length of ear ; fusion 
and distortion of helix, anthelix, antitragus, and 
lobule. 





Fie. 296. — Triplication of crura furcata; mal- 
formed helix and antitragus ; absent lobule. 



Fig. 297.— Fissure in anthelix; slight Darwin 
tubercle ; slight antitragus. 






Fig. 298. — Mo crus superius ; Fig. 299. — Xo lobule; no 

no anthelix ; small fossa con- fossa conchse ; shallow fossa 
chse ; few details of ear. scaphoidea ; fusion of helix, 

anthelix, and antitragus ; a tvpe 
of Stabl ear, Xo. 3. 



Fig. 300. — Prominent anthe- 
lix; maldeveloped helix; ab- 
sence of lobule ; diminution of 
the concha; Wilderniuth ear, 
Xo. 1. 



were apparently normal persons. As regards heredity, it is very com- 
mon for children to inherit ears with the identical characteristics of 
those of one or the other parent, but, on the other hand, it is not uncom- 
mon for the ears of the children to be quite different. 



GENERAL ETIOLOGY OF INSANITY. 



711 



Anomalies of the Limbs. — Paralysis, atrophy, retarded growth, 
club-foot, and athetosis are conditions due to disease of the brain, and 
are observed in many cases of paralytic idiocy. These are not properly 
stigmata of degeneration, although they may be such under some cir- 
cumstances, as, for instance, when club-foot or club-hand has a terato- 
logical origin. On the other hand, there are anomalies having a 
hereditary character, which are essentially degenerative indices. Among 
these may be mentioned congenital luxations, supernumerary fingers or 
toes (polydactyly ), fusion of fingers or toes (syndactyly or aschistodactyly), 
excessive length of the arms as compared with the rest of the body and 
the lower limbs, missing fingers or toes (ectrodactyly), missing limb 
(ectromelus), fusion of the extremities (symelus or symmelus), or ab- 
sence of parts of limbs so that they 
are excessively short (phocomelus). 
There may also be anomalous brevity 
of some digits as compared with the 
relative proportions of normal digits. 
Excessive volume of limbs (megal- 
omelus) or digits (megalodactyly) or 
excessive gracility of limbs (oligo- 
melus) or of digits (oligodactyly) also 
deserve mention. 

Anomalies of the Body in 
General. — Local malformations are 
naturally of more importance than 
general anomalies of the whole form, 
but it is necessary to study the rela- 
tive proportions of the entire figure 
from an anthropometrical point of 
view, and to compare the results with 
normal standards. Excessive dim- 
inutiveness of figure, as well as ex- 
cessive or giant growth, are indications 
of degeneracy. So, too, are infantile 
characteristics in an adult, feminine 
peculiarities in males, and masculine 

traits in females. In this regard, observations of the relative 
portions of the shoulders and pelvis are particularly useful, 
occult form of spina bifida with local hypertrichosis is met with. 
Deviation of the vertebral column among neuropaths is mentioned by 
Fere. They may be lordoses, scolioses, or kyphoses in various degrees. 
The coccyx may present peculiarities, such as simulation of a tail. 
Thoracic asymmetry or other deformity is observed at times. Absence 
of pectoral muscles, or of muscles in various parts of the body, has 
significance. Hernise are evidence sometimes of arrest of development 
of some part of the abdominal wall. Excessive development of mam- 
mary glands in males, or their absence or reduplication (polymastia) in 
either sex, constitutes an evidence of degeneracy. 

Anomalies of the Genital Organs. — Among the genital anomalies 




Fig. 301.— Phocomelus right arm in epi- 
leptic girl ; right humerus several inches 
shorter than left ; arms otherwise perfect. 



pro- 
The 



712 



MENTAL DISEASES. 



in males are cryptorchismus ; unilateral or bilateral microrchidia ; 
spurious hermaphroditism ; insufficient development of the entire genital 
apparatus ; hypospadias ; epispadias ; defect, torsion, or great volume of 
the prepuce ; median fissure of the scrotum ; imperforate meatus. 

In females the labia may be abnormally large, simulating a scrotum ; 
sometimes very small. The clitoris may be exceedingly large. The 
labia minora may be hypertrophied. Sometimes there are intermediate 
folds between the labia minora and labia majora. The labia minora 
may be pigmented, particularly in brunets and when they are hyper- 
trophic. There may be imperforate vulva, or atresia of the vagina, or 
double vagina ; uterus bicornis is sometimes met with. 

Anomalies of the genito-urinary apparatus should always be sought 
for, for, though most frequent among idiots, imbeciles, epileptics, and 
the like, they are by no means rare in other classes of degenerates and 
in degenerate families. In males, defect of the testicles often coincides 

with general excess of growth in 
the whole body or in the lower 
extremities, such as is often pro- 
duced by castration in man and 
lower animals. 

Anomalies of the Skin. — 
Among the anomalies of the skin 
are to be mentioned adipose 
thickening ; polysarcia ; preco- 
cious and often abnormal devel- 
opment of the hairy system ; hair 
along the spinal column ; rudi- 
mentary tail ; premature gray- 
ness ; a glabrous chin in grown 
men ; persistent lanuginous char- 
acter of the hair ; excessive growth 
of hair on the chin and breast in 
women ; complete or partial dis- 
coloration of the hair (albinism, vitiligo) ; local or general hypertri- 
chosis ; partial or complete absence or fetal state of the nails ; melanism 
of the skin ; pigmentary or vascular nevi ; molluscum ; ichthyosis ; 
vitiligo ; albinism ; pigmented spots. 

Anomalies of Motor Function. — Delay in acquiring a knowledge 
of the proper use of muscles for walking, eating, and the like may 
often be regarded as an index of degeneracy. Where ordinary etio- 
logical factors may be excluded, tremors, tics, epilepsy, and nystagmus 
may have a similar value. Even when not congenital, they often indi- 
cate hereditary instability of the nervous system. 

Anomalies of Sensory Function. — The numerous anomalies of 
function in connection with the eye have already been mentioned. 
Congenital deafness has also its significance. So, too, have hereditary 
forms of migraine and neuralgia. Certain defects or excesses in general 
cutaneous sensibility have been noted as frequent among degenerates. 
Thus several excellent writers on this subject have stated that a 




Fig. 302. — Hypertrichosis in a female imbecile. 



GENERAL ETIOLOGY OF INSANITY. 713 

general anesthesia is not uncommon, especially among lower classes 
of degenerates. In some instances there is hyperesthesia. 

Anomalies of Speech. — It may be questionable as to how far 
stammering and stuttering are to be looked upon as functional degen- 
erative stigmata, but they are certainly found more often in children 
with a neuropathic inheritance than in children with good heredity. 
Delay in the acquisition of language and complete or partial defect of 
speech have more significance. 

Anomalies of Genito-urinary Function. — Sexual irritability, 
impotence, sterility, and urinary incontinence must be considered as 
indices of neuropathic disposition. Retardation of puberty in both 
sexes, but especially in the male sex, is a noteworthy indication. 

Anomalies of Instinct or Appetite. — It has been pointed out 
that, among all degenerates, there is a taste or appetite for certain foods 
or drugs which tends to favor their dissolution (alcohol, morphin, 
cocain, and the like). In many cases of inebriety the uncontrollable 
appetite is to be looked upon as a functional stigma of neuropathic 
inheritance. Gluttony, merycism, and the like are usually similar indi- 
cations. 

Miscellaneous. — A diminished resistance against external influ- 
ences (such as strains of various kind) and diseases is significant. 
Great precocity of intellectual development and of certain aptitudes, 
and morbid emotional conditions, are among suspicious indications of a 
neuropathic basis. 

The psychic stigmata of degeneracy need only the foregoing enu- 
meration. 



PHYSICAL AND MENTAL STRAIN. 

At the beginning of this chapter I spoke of the etiology of insanity 
as being describable in two terms, heredity and strain — heredity, which 
renders the nervous organization unstable, the strain, which causes the 
unstable nervous centers to collapse. Doubtless there are limits of en- 
durance in any organization, no matter how strongly balanced, if the 
strain be great enough, but the instances of insanity developing in indi- 
viduals with properly balanced and adjusted nervous organizations are 
rare indeed. The strain which breaks the unstable nervous system is 
physical or moral, often both. What organism could withstand the 
assaults upon its integrity of all three of these factors — heredity, 
physical ill-health, and cankering care? It is difficult to estimate 
accurately the proportion of one cause as compared with another, since 
usually several are associated in the same case ; but I believe that 
statistics will support me in the statement that the physical causes (in 
which I include alcohol, bodily diseases and disorders, accident and in- 
jury, old age, the puerperal state, the menopause, and the like) surpass 
the moral causes (grief, domestic trouble, business worry, overwork, 
religious excitement, love affairs, fright, nervous shock, etc.) as factors 
in insanity by about two to one — that is, twice as many are made in- 
sane by physical strain as by mental strain. It now behooves us to 



714 MENTAL DISEASES. 

examine these divers stresses, and to show how some of them give a 
special color or character to the psychosis developed. It is best to pre- 
sent them somewhat in the order of their frequency, under two or three 
categories, the most common and most important first, the rarest last. 
The physical, physiological, and moral causes, then, will be considered in 
the following order : 

Physical : 

1. Toxic (autotoxins, alcohol, narcotics, metallic poisons, etc.). 

2. Bodily diseases and disorders (syphilis, acute and chronic diseases of 

the nervous system). 

3. Trauma to the head. 

4. Nervous exhaustion. 

Physiological : 

1. Puberty. 

2. Puerperal state. 

3. Menopause. 

4. Senility. 

Moral: 

1. Emotional strain. 

2. Imitation. 

Toxic Influences. — It is not surprising that deleterious agents in 
the blood, which bathes every cell and fiber of the nervous system, 
carrying thither the necessary nutritional elements and removing 
thence the waste products, should readily overstimulate, retard, 
pervert, or destroy its high functions. Some of these agents (like 
alcohol) also affect the nutrition of the central nervous system, by in- 
ducing disease of the arteries and of the stomach, liver, and kidneys. 
Some of the poisons cause insanity by long-continued chronic action 
upon the nervous system, and others by acute intoxication. 

Auto-intoxication. — Accumulation of deleterious agents in the 
blood in such quantity as to affect the nervous system — e. g., carbonic 
acid and the poison of diabetes and of uremia — has been long known to 
medical science ; but the more mysterious poisons produced by disease 
in various parts of the body, by fermenting or putrefying substances in 
the alimentary tract, and by some of the acute infectious fevers, have 
only of late taken an important place in the etiology of the psychoses. 
We do not yet know how frequently auto-intoxication from absorption 
of intestinal poisons determines insanity, but the facts thus far collected 
point to the origin of a considerable number of cases from this cause. 
These cases are usually of depressed type, but sometimes maniacal. 

Alcohol. — While the position of autotoxemia as a factor in etiology 
is not yet determined, we may say of alcohol that it stands foremost 
(after heredity) as a single, independent cause (eighteen to twenty per 
cent, in males). Acute alcoholism rarely induces a psychosis. Alcoholic 
insanity commonly develops from chronic alcoholism, from the excessive 
use of the poison for a long period of time. It is three or four times 
as frequent as a factor in the insanity of males as of females. Usually 
it is not difficult to discover the cause of an alcoholic insanity, 
but, should alcoholic abuse be denied, an investigation of the condi- 



GENERAL ETIOLOGY OF INSANITY. 715 

tion of the viscera will often throw light upon the subject (cirrhosis 
of the liver, fatty heart, chronic gastric catarrh with heavily furred 
tongue, chrome nephritis, and arteriosclerosis). Corroborative evidence 
will generally be afforded, too, by affections of the nervous system 
(alcoholic polyneuritis ; alcoholic epilepsy ; muscular paresis here and 
there in the hands, face, or tongue ; fibrillary tremor of the face and 
tongue, fine or coarse tremor of the fingers and hands ; paresthesias, 
hyperesthesias, neuralgias ; muscse volitantes, tinnitus aurium, ambly- 
opia, and visual hallucinations, sometimes pupillary paralysis.) 

The alcoholic psychoses may be classified as follows: 
Pathological drunkenness. 
Delirium tremens. 
Acute hallucinosis. 

Korsakoff's psychosis (or polyneuritic psychosis). 
Chronic alcoholism. 
Alcoholic paranoia. 

Pathological drunkenness differs from ordinary drunkenness by the 
manifestation of sudden strong anxious affects with blind motor explo- 
sions, or of melancholia symptoms, or of mania-like attacks. The dura- 
tion is short, followed usually by deep sleep and amnesia. Pathological 
drunkenness is the type found among disequilibrates of all kinds, and 
among feeble-minded, epileptics, hysterics, neurasthenics and the like, 
who are generally intolerant of alcohol. The diagnosis may be aided by 
rinding pupillary paralysis and by experimental determination of alcohol- 
intolerance. 

Delirium tremens is an acute psychosis in chronic alcoholism, 
lasting an average of four days, with 10 to 15 per cent, of mortality, char- 
acterized by complete sleeplessness, wide-spread general tremor, disorient- 
ation as to time and place, zooscopic hallucinations, and sometimes epi- 
leptiform attacks. 

Acute alcoholic hallucinosis is a psychosis lasting a few days or 
weeks, characterized by crowding hallucinations of hearing and paranoid 
ideas (delusions of reference, persecution, and jealousy), but without 
disorientation. 

Korsakoff's psychosis is a syndrome in which are found multiple 
neuritis, defect of recent memories (disorder of retention), retroactive 
amnesia, and confabulation. 

Chronic alcoholism presents defects of intelligence and of old and 
recent memory, together with moral deterioration, complete lack of in- 
sight, and occasional epileptiform attacks. 

Alcoholic paranoia is observed in some cases of chronic alcoholism. 
Paranoid ideas are developed, and are more less systematized. The 
most common delusion is that of jealousy or infidelity; the delusions of 
poisoning are also common. 

Morphin. — Morphin is, among the alkaloids, the most frequent 
cause of insanity. It is a sad commentary on the heedlessness of some 
medical men, but the family physician is responsible in almost every 
case of development of the morphin habit and its far-reaching conse- 
quences. It should be looked upon as a sin to give a dose of morphin 
for insomnia or for any pain (such as neuralgia, dysmenorrhea, rheuma- 



716 MENTAL DISEASES. 

tism) which is other than extremely severe and transient. The earliest 
symptom of morphinism is a general sensation of disquiet, manifested 
by incoherence of thought, difficulty of concentration of the mind, 
marked motor restlessness, and insomnia. The dose is gradually in- 
creased, and may reach a maximum of five or more grams. 

The chief physical disorders induced by long-continued use of 
morphin or opium are as follows : 

1. Anorexia and constipation (later, diarrhea often). 

2. Cachectic anemia. 

3. Cardiac weakness and intermittence, and bradycardia. 

4. Muscular weakness with tremor. 

5. Miosis in the early stages, mydriasis later, with sluggish re- 
action of the pupils. 

6. Impotence. Amenorrhea in women. 

7. The knee-jerks are often absent. 

8. Diminished sensibility to touch and pain, and concentric limi- 
tation of the visual fields. 

9 Headaches and localized shooting pains, neuralgias, and pares- 
thesias. 

10. Sensation of feeling cold. 

The psychic symptoms may be summarized briefly, thus : 
1. Simple elementary illusions and hallucinations, muscse volitantes, 
tinnitus aurium. 

2. Loss of will and esthetic sense, irritability ; moral perversion, as 
in alcoholic psychic degeneration, but with little failure of memory. 

3. Diminished attention, incoherence of ideas, and easily fatigued 
intellectual powers. 

A well-developed psychosis is usually the result of abstinence from 
morphin, and not of the chronic misuse of it. It varies in degree up 
to a type approaching acute mania. 

Cocain. — Of recent years there have been numerous instances of 
cocain insanity, and they are doubtless growing more frequent. While 
with morphin it is the abstinence that is prone to induce a psychosis, 
with cocain, on the contrary, it is the prolonged use of the drug that 
develops the insanity, while abstinence gives rise to few noteworthy 
symptoms. The misuse of cocain leads to the evolution of an acute 
hallucinatory paranoia, 

Hashish (Cannabis Indica). — We never see insanity from this 
cause in America, but in Egypt and India it is extremely common. In 
visits paid by the writer to the Cairo Insane Asylum in the winter of 
1891-92, he observed 64 cases of the 248 patients in the institution 
in which the insanity was due to the inhalation of hashish by smoking. 
The symptoms produced are indigestion, diarrhea, increased appetite, 
dilatation of the pupils, drooping eyelids, anemia, general debility, and 
delirium. The earliest mental symptom is marked and increasing 
timidity, sometimes amounting to folie du doute, or an agoraphobia. 

Atropin ; Hyoscyamin ; Hyoscin. — These isomeric alkaloids have 
much the same physiological effects (mydriasis, paralysis of accommo- 
dation, dryness of the throat, depressed heart's action, dreadful illusions 
and hallucinations, etc.), but instances are not common of their giving 



GENERAL ETIOLOGY OF INSANITY. 717 

rise to psychoses. However, it is probable that the employment of one 
of these as a secret cure for drunkenness has been the cause of serious 
insanity in a considerable number of cases that have found their way 
from sanatoriums to asylums. 1 

Metallic Poisons. — Lead and mercury at times induce insanity, the 
former much more frequently than the latter. The intoxication is 
chronic, but the psychosis developed may be either acute or chronic. 
Both of these poisons produce similar psychic symptoms, such as ver- 
tigo, sleeplessness, rudimentary or marked hallucinations, confusion and 
incoherence, anxious depression, and often persecutory delusions. In 
severe cases there is dementia. In lead cases there are usually to be 
observed the concomitant physical symptoms, such as anemia, colic, 
blue line on the gums, tremor, arthralgia, palsies, and convulsions. In 
mercury cases we note stomatitis, tremor, and gastro-intestinal catarrh. 
Hysterical symptoms are not infrequently superadded upon the lead 
and mercury psychoses. 

Various Poisons. — There are many other poisons which, in rare 
instances, produce insanity. Among these may be mentioned coal-gas, 
carbonic oxid, stramonium, henbane, hemlock, bisulphid of carbon, 
etc. The writer described some years ago three cases of bisulphid of 
carbon insanity which ran their course under the type of acute mania 
going on to recovery, studied by him at the Hudson River State 
Hospital for the Insane. 2 All three were workers in a rubber 
factory. 

Bodily Diseases and Disorders. — Syphilis. — Syphilis is one of 
the most important of the physical causes of insanity. It acts upon 
the brain indirectly through wide-spread, severe disturbance of general 
nutrition and through arteriosclerosis, and directly by the production 
of diffuse changes in the tissues of the central nervous system, or of 
circumscribed meningeal deposits or intracerebral gumma ta. The degen- 
eration of cells and fibers, the gliosis and the arteriosclerosis, are possibly 
due to toxins created by specific micro-organisms, and not to the direct 
influence of the germs themselves, which may explain why syphilitic 
psychoses are ordinarily late manifestations of syphilis. General 
paralysis and cerebral syphilis are the chief phases in which the psy- 
chosis is presented. It is often difficult to obtain a history of syphilis 
in a patient, so that the statistics as to the frequency of syphilis as a 
cause of general paresis, for instance, are generally faulty. Where the 
history is uncertain, a careful examination may indicate the existence 
of syphilis (hereditary syphilis in the children, leukoderma, cicatrices, 
swelling of the lymph-glands, periosteal deposits and tophi, perforation 
of the palate, nasal symptoms, etc.). 

Hereditary syphilis plays a part in the etiology of the psychoses of 
early life, — for example, imbecility and idiocy, — though probably not 
so great a part as is frequently asserted, for, in a considerable experience 
with such conditions at the Randall's Island Asylum for Idiots, I have 
seen but little hereditary syphilis. 

1 Dr. B. D. Evans, Superintendent of the Morris Plains Asylum, N. J., has col- 
lected a number of such cases. 

2 "Boston Med. and Surg. Jour.," Oct., 1892. 



718 MENTAL DISEASES. 

Infections. — Typhoid fever, malaria, pneumonia, influenza, and acute 
articular rheumatism head the list of acute fevers which sometimes super- 
induce insanity. Disturbances of nutrition, high fever, and toxic changes 
in the blood are responsible for the symptoms developed. Perhaps the 
toxin-producing bacteria are the chief agents, acting by direct influence 
upon the cortical cells and fibers. If this be true, these cases were better 
classed under the head of Toxic Influences. At the height of a fever 
we have a febrile delirium, characterized by hallucinatory incoherence ; 
but later on, when the fever has diminished and the organism is weak- 
ened by disease, such manifestation is termed " inanition delirium." 
From either the febrile or inanition delirium a psychosis may develop, 
usually assuming the type of a hallucinatory paranoia with self-depre- 
ciatory or persecutory delusions, in some cases with a tendency to agi- 
tation, in others with inclination to a stuporous condition. Manic or 
melancholic symptoms are rare ; stupidity with a proclivity to terminal 
dementia, more common. Malarial psychoses sometimes exhibit a cer- 
tain periodicity, corresponding to the intermittent nature of the cause. 
Heredity, alcoholic degeneration, etc., also play a considerable part in 
the etiology of this form of toxic mental disorder. 

Tuberculosis. — The disturbances of nutrition in tuberculosis, as 
well as the mental depression sometimes associated with the disease, 
occasionally lead to the development, out of an exhaustion or inanition 
delirium, of a true psychosis — a melancholia or a hallucinatory excite- 
ment. It may be said, however, that the relation of tuberculosis to 
insanity is much more frequently that of sequel than of prodrome, for 
many cases of melancholia and stuporous forms of insanity die of this 
disease owing to shallow respiratory functions and insufficient nutrition. 

Carcinoma. — The progressive cachexia induced by malignant dis- 
ease, as well as the direct effects of cerebral metastases, sometimes lead 
to psychopathic conditions resembling those of tuberculosis. 

Heart Disease and Atheromatous Arteries. — Cardiac disease is 
frequently found among the insane, but its precise relation to the 
psychoses is obscure. Doubtless, in so far as it disturbs the circulation 
and interferes with cerebral nutrition, it predisposes to mental instability. 
On the other hand, disease of the arteries (senile, nephritic, syphilitic, 
alcoholic, cachectic), is a much more effective disturber of nutrition, 
and at the same time gives rise to serious focal lesions, such as miliary 
aneurysms, thrombosis, and hemorrhage, which may be etiologically 
associated with various psychopathies. 

Nephritis. — The nephritic psychoses assume usually the type of a 
hallucinatory paranoia, and therein resemble other toxic insanities. It 
is probable that toxic changes in the blood are here of more importance 
than the changes in the vascular walls, though these, too, have their 
significance. 

Gastro -intestinal Disorders. — These sometimes induce hypochon- 
driacal melancholia, and predispose to psychoses of various kinds by 
disturbing nutrition ; but their frequent relation to insanity is generally 
a consequence rather than a cause. 

Diseases of the Genital Organs. — There are serious disorders of 



GEXERAL ETIOLOGY OF INSANITY. 719 

the female genital organs which occasionally play a role in the causa- 
tion of insanity, but their importance as factors has been grossly 
exaggerated, and much harm and little good have followed operative 
interference for the relief of the insanity. Probably the cessation of 
menstruation (usual in acute insanities) has been misinterpreted as 
significant of genital disease, and thus given rise to a grave error. 

I would not be understood as decrying operative or other treatment 
altogether, if such be indicated ; but let no one be deceived into expect- 
ing benefit from the procedures, except in rare instances. 

Having briefly examined most of the general physical disorders 
which are concerned in the causation of insanity, we will now turn our 
attention to certain functional diseases of the nervous system which, by 
reason of their localization in the cerebral cortex, are prone to assume 
a very important part in psychopathology. These are epilepsy, hysteria, 
and chorea. 

Epilepsy. — Epilepsy is almost as common a disease as insanity 
itself. Asylum physicians, whose experience with epilepsy is limited to 
cases associated with mental disorder, tend to overestimate the frequency 
of insanity among epileptics. Thus, it is often stated by them that psychic 
degeneration is manifested in sixty to eighty per cent, of all epileptics. 
But the fact is that probably not more than ten to fifteen per cent, of 
epileptics develop insanity ; at the same time the proportion is so large 
as to show a close relation between this functional cortical malady and 
mental disorders. When progressive epileptic degeneration occurs, it 
manifests itself by the following symptoms : 

1. Slowness of ideation and articulation. 

2. Abnormal irritability of temper. 

3. Hypochondriacal depression. 

4. Paranoid outbreaks of various kinds. 

5. Dementia. 

Hysteria. — Hysteria is also a functional neurosis of the cortex, 
often closely associated with divers psychoses. There is a species of 
hysterical psychic degeneration, and the neurosis frequently gives a 
special color to different forms of insanity. The symptoms noted 
(aside from the peculiar sensory and motor manifestations familiar to us 
in simple hysteria) on the mental side are as follows : 

1. Lack of logical coherence and sequence of thought, but with 
perfect intelligence. Defects of memory, with rudimentary persecutory 
and erotic delusions, are encountered frequently. 

2. Extreme uncontrolled and morbidly changeable emotions. Pro- 
found egotism. 

3. Frequent illusions ; occasional hallucinations. 

4. Conduct and speech are based upon emotional impulsiveness, un- 
controlled by ethical considerations of any kind. 

Organic Nervous Diseases. — The psychic disorders induced by 
organic processes in the brain, such as meningitis, tumor, softening, 
hemorrhage, and the like, are characterized either by symptoms of re- 
tardation of functions or by symptoms of irritation, and are due either 
to pressure or to the indirect influence of the lesion upon the circula- 



720 MENTAL DISEASES. 

tion or nerve-centers and tracts. Emotional irritability, hallucinations 
of the various senses, defects of intelligence reaching to imbecility or 
idiocy, stuporous conditions — these are common mental manifestations 
of such processes. Since single localized lesions are apt to produce slight 
mental changes, any marked intellectual defect or multiform psychic 
symptoms may be looked upon as suggestive of wide-spread, perhaps 
multiple, lesions, such as multiple sclerosis, multiple tumors, syphilis, 
etc. Sometimes true insanities develop in these cases, particularly 
when there is hereditary instability of nervous organization. 

Trauma to the Head. — A blow upon the head is one of the most 
direct of stresses to which the brain can be subjected. It is not so 
much the local effect of the injury (which, indeed, would not present 
psychic symptoms differing materially from those of any other local 
lesion of the brain such as have just been considered), but the general 
effect of a commotio cerebri that we are called upon to consider. The 
syndrome of mental disorders induced by such cause has been well 
termed by the Germans " commotion insanity. " The effect of a violent 
blow, jar, or jolt to the head must have some influence upon the mole- 
cules of the brain as well as upon the encephalon as a mass, must dis- 
place and disarrange delicate microscopic structures, such as the cells 
and fibers. If the blow be insufficient to produce complete loss of con- 
sciousness, there will be a dazed, bewildered condition, and the patient 
will struggle or grope about in a confused way. There may be a loss 
of memory, more or less extensive, as a result. Naturally, the newest 
organizations of tissues, being the most fragile, will be the most easily 
disarranged ; hence, with amnesic defects, it will be the most recent 
acquisitions, or such as cluster about the time of the injury, which will 
suffer most. The patient will experience strange sensations in his 
head. The head may feel as if it were going around. Objects seem 
to move. There is a feeling of being intoxicated or of dizziness. A 
general hyperesthesia and hyperalgesia are not uncommon, while a 
hypalgesia is occasionally observed. Among psychic symptoms hallu- 
cinations and painful effects are prominent, generally of a terrifying 
nature. Associations may be so interfered with as to induce difficult 
ideation, mental confusion, and a genuine primary incoherence. The 
motor expressions are often characteristic, consisting of catatonic con- 
ditions, impulsive acts of violence, and aimless wandering about. In 
some cases no particular results of the trauma are noted until the lapse 
of a few hours or days, when suddenly the traumatic psychosis de- 
velops. After the psychosis has run an acute course, a condition of 
chronic insanity or of a secondary dementia may follow. Such a 
secondary dementia may simulate very closely general paresis, particu- 
larly if it be progressive. It can not be said that there are any well- 
authenticated cases of true general paralysis dependent upon trauma- 
tism. 

There are not infrequently instances of the creation, by trauma to 
the head which has induced no direct evil consequences, of an unstable 
nervous system, of a predisposition upon which other etiological factors 
may operate later in life. 



GENERAL ETIOLOGY OF INSANITY. 721 

Insolation probably acts upon the brain in a manner similar to trau- 
matism. 

Exhaustion. — Stresses of various kinds, mental or physical, espe- 
cially in conjunction with the impairment of the nutrition of the central 
nervous system, induce an exhaustion upon the basis of which a psychosis 
may develop. The mental strain may be from overwork, overstudy, 
insomnia, and the like ; the physical, from masturbation, sexual excess, 
hardships. The nutritive impairment is the result of some blood-change 
or deficiency, such as constitutional anemia, a cachectic state, etc. The 
physical symptoms of such exhaustion are : slowing of the thought 
processes, difficulty of recollection, want of ability to concentrate the 
attention, rapid fatigue on mental exertion, emotional irritability with an 
undertone of depression, leading often to fully developed insanities, 
which are designated as asthenic psychoses. The common features of 
such psychoses are retardation and incoherence of the mental processes, 
manifested even in the quality of the hallucinations and delusions. But 
almost any form of insanity may be evolved from this asthenic state of 
the nervous system, such as manic, neurasthenic, stuporous states, and 
various paranoid conditions. 

As Ziehen points out, it is also interesting to observe how any ex- 
hausting psychosis may in itself induce this asthenic condition with the 
characteristic features of an asthenic psychosis, as a result of which we 
have a secondary type of mental disorder developed upon the basis of 
the original insanity. 

Physiological Factors. — Puberty, the puerperal state, the climac- 
teric, and senility are indirect strains to which the organism is subject, 
by reason of the more or less profound physiological commotions they 
arouse in the nervous system — commotions which may well disturb the 
normal adjustment and equipoise of the thousands of delicate processes 
going on in the brain, and thus enormously increase its vulnerability to 
the direct factors which beget insanity. 

The curve of psychic morbidity reaches its highest points, corre- 
sponding to maximal aggregations of etiological factors in both sexes, at 
puberty, middle age, puerperal periods, the climacteric, and senility. 

Puberty. — From the thirteenth to the twentieth year there are re- 
markable changes, physical and mental, in the growing individual. 
These are more noteworthy in the female than in the male sex, for the 
time is shorter for the change from girlhood to womanhood than from 
boyhood to manhood. The evolution of the sexual characters and the 
development of the powers of reproduction induce a stream of innu- 
merable new stimuli from the genital organs to the brain, accompanied 
by wholly new organic sensations, new associations, and new and power- 
ful emotions. The evolution is rapid, and, as is the case with all rapid 
development, more or less unstable. 

The boy grows fast in body, takes on the aspect of manhood, with 
a stronger and more rugged frame, a changing voice, a budding beard. 
His mind is filled with new sensations, emotional, sentimental, amatory, 
and with changing, fantastic, illusory dreams and imaginings. Even in 
the normal youth this nascent state, this struggle of the emotions, 

46 



722 MENTAL DISEASES. 

thoughts, instincts, impulses for new associations and new combinations, 
may be greatly aggravated in many cases by masturbation, in others by 
nutritive disorders. If this be so with the normal individual, how 
much greater must be the stress of puberty to the individual with a 
constitution vitiated by hereditary taint ! 

The girl leaps more quickly into her place in life. The physical 
changes are more rapid in her, and at the same time more varied and 
noteworthy. It is a time of tumultuous activity of mind and body in 
an organism which has not the numerous outlets for surplus energy 
possessed by the other sex. 

The psychoses of puberty are various in their expression. They 
may manifest themselves as a mania, a melancholia, a paranoia, or as an 
insanity with peculiar color, to which the name hebephrenic modification 
has been given ; so that we speak of a hebephrenic mania, a hebephrenic 
melancholia, etc. 

By the designation hebephrenic is understood the following syn- 
drome : Extraordinarily rapid and paradoxical changes (depressed ideas 
in the midst of boisterous gaiety, jocularity in the deepest depression), 
with paradoxical facial expression and paramimia ; exalted motor 
activity (laughing, dancing, grimacing, exhorting after the manner of 
an orator, often with incomprehensible words and sentences) ; conduct 
and action without apparent object, but often with the semblance of 
desiring to attract attention. 

Puerperal State. — Pregnancy, parturition, and lactation diminish 
the vitality of woman, debilitate and weaken her entire organism, 
induce a species of physiological commotion in her nervous system, and, 
in short, bring to bear a strain upon her which is, even under normal 
conditions, attended by emotional irritability, depression, morbid yearn- 
ings, etc. It is not strange, therefore, that the puerperal period in 
women with unstable nervous systems should often be an exciting factor 
in the development of psychoses of various kinds. In about ten per 
cent, of insane women the insanity has its origin at the epoch of repro- 
duction. The majority of these cases are parturitional (seven and a 
half per cent.), while about a fourth are lactational and a tenth preg- 
nancy cases. It is perhaps true that there are many cases of partu- 
ritional psychoses in which the insanity is not so much due to the stress 
of labor as to possible auto-intoxications from poisonous substances 
absorbed during the catabolic changes incident to subinvolution of the 
enlarged uterus. As important factors, too, we must include loss of 
blood, parametritis, sepsis, mastitis, etc. 

There are divers forms of insanity consequent to the puerperal state, 
such as acute hallucinatory paranoia, melancholia, stuporous insanity, 
mania, and neurasthenic insanity. 

Menopause. — The climacteric, between the ages of forty and fifty, 
is another epoch of change in woman, a period of involution in its way 
analogous to the evolution at the age of puberty. There is a physio- 
logical commotion in the nervous system at the time of the cessation 
of ovulation and menstruation, a clisequilibration associated, even in 
normal individuals, with numerous neurotic manifestations, and, in such 



GENERAL ETIOLOGY OF INSANITY. 723 

as have unstable organizations, attended with peril to the mental in- 
tegrity. Melancholia, simple and hallucinatory paranoia of chronic 
character, and circular insanity are the forms of psychosis incident to 
the menopause. About four per cent, of the cases of insanity in women 
are due to the climacteric. 

Senility. — The involution of all the tissues of the body characteristic 
of especially the seventh decad of life forms also a frequent basis for 
insanity which depends, in the main, upon the loss of functional activity 
in the cerebral cortex. Such loss is notable even in normal individuals. 
The latest acquisitions of the mind are the least stable ; hence the con- 
spicuous loss of memory for events of recent occurrence and the ten- 
dency to live in the past. The scope of interests, sympathies, and ideas 
narrows itself down to the individual's immediate physical comfort and 
needs. While the physiological involution of senility belongs to the 
seventh decad, in many instances it begins long before this, OAving to 
general debility, endarteritis, etc. Marked changes in the brain of 
such nature must, therefore, often superinduce veritable psychoses in 
individuals predisposed to mental disorder by heredity or by antecedent 
physical or psychic stresses. 

Senile insanities manifest themselves in many forms, — melancholia, 
mania, incoherent paranoia, hallucinatory paranoia, dementia, — but, of 
course, modified from the common types by the weakening of the cor- 
tical functions previously described. Vertiginous seizures, slight pare- 
ses, dreadful hallucinations, and primary anxious conditions are often 
observed in all of these forms. 

The hallucinations appear in senile forms in psychoses which ordi- 
narily run their course without them, and the anxious states in ordinarily 
non-affective insanities. 

Moral Causes. — About twenty-four per cent, of all cases of insanity 
are ascribed to moral causes, among which are classed domestic troubles, 
grief over death of friends, business worries, anger, religious excitement, 
love affairs, fright, and nervous shock. The percentage is greater in 
women than in men. It is doubtful if any emotion alone can overcome 
the stability of the normal nervous system ; hence it is in the fragile, 
nervous constitutions of individuals tainted by heredity that extreme 
emotions are wont to exert their malign influence. 

The uncertain equilibrium of the highest nerve-centers in these cases 
is all too readily overcome by the tumultuous wave of an intense 
emotional impression. Possibly, the results depend upon disturbance 
of the vascular innervation. Ordinarily, the greater and more sudden 
the emotion, the greater the liability of the badly poised brain to suc- 
cumb ; but, like the drops that wear away the stone, an emotion of less 
intensity may, by long continuance, produce equally disastrous conse- 
quences. Some acute psychoses may be suddenly developed by fright, 
or a transitory emotional insanity for a few hours or for a few days in 
duration. Among the symptoms are mutism, or incoherence, confusion, 
isolated hallucinations, delusions, with impulses to violence and aimless 
wandering, followed later by complete, or nearly complete, amnesia. 

The more slowly working affects, like sorrow and worry, often aid in 



724 MENTAL DISEASES. 

the evolution of melancholia, paralytic dementia, or acute or chronic 
paranoia. 

Herbert Spencer long ago showed that our life is a series of constant 
adjustments of internal relations to external relations, and it is only of 
late that we have begun to apply his lucid explication of this process of 
the normal mind to our study of what goes on in the abnormal rnind. 
This has led to a new valuation of the moral cause, by which we always 
meant mental cause, and for which we now employ the adjective 
psychogenic. We have come to believe that insanity is more often of 
psychogenic origin than we formerly supposed. This may have its rise 
in some psychic trauma, some sudden shock or profound emotion, or it 
may start from some minor maladjustment of "the internal relations to 
the external relations, " some small disorder of the individual's reactions 
to the realities about him, leading to a whole series of wrong adaptations 
that finally result in actual mental disorder. The result of this sound 
view is a more thorough study nowadays of the patient as an individual, 
rather than as an ordinary type of insanity, and, consequently, a better 
system of therapy. 

Imitation. — The so-called psychic infection never influences normal 
individuals who are brought into contact with the insane. Physicians, 
attendants, and others who have to do with the insane are never 
affected, except when morbid heredity and mental and physical over- 
work combine to prepare the soil for the development of a psychosis. 
The writer recalls but one instance of an attendant being mentally 
unbalanced during her service. She was neurotic by constitution and 
cut her throat a few days after one of her patients had committed sui- 
cide in the same manner. But there are not infrequent instances of 
communicated insanity among members of a family. 

The simultaneous development of insanity in two or more persons 
associated together, or the imposition of delusions gradually arising in 
the mind of one upon the impressionable intellect of a second, third, or 
of many persons, has been described under the names Folie a Deux, Folie 
Simultanee, Reciprocal Insanity, Folie Imposee, etc. There are several 
factors which govern the evolution of such insanities. In both forms a 
degenerative soil is usually required for the proper germination and 
growth of morbid ideas. In the simultaneous variety there must be, in 
addition to predisposition, that similarity of intellectual substrata which 
Ave find particularly in persons who are blood-relations or who are inti- 
mately joined together by mutual like and dislike ; hence it is that 
brothers or sisters most frequently manifest simultaneous insanity. 
Take two healthy children of one family and bring them up far apart, 
yet there will be innumerable physical resemblances between them, and 
many peculiarities in their character and conduct which prove them to 
be consanguineous ; if a hereditary instability of nerve-cells had been 
implanted in them, there Avould be a tendency to a similar form of dis- 
solution, even if they remained apart. How much greater would this 
be in two persons so intimately associated as sisters, for instance. In 
children the study of unconscious imitation is one of great interest. 



GENERAL ETIOLOGY OF INSANITY. 725 

Who has not observed the identity of intonation of phrases, of gesture, 
of laughter, of many facial expressions, of certain habits, in children 
either related or brought up together ? Such unconscious imitation, as 
is well known, may lead in children to the contraction of certain nervous 
and even mental diseases. The contagious quality of emotions is well 
established. An explosion of laughter will call up smiles on even 
melancholy faces in a crowd. A pathetic scene on a stage will bring 
tears and depress the oral angles in a large audience. The unconscious 
imitation of gestures, such as bowing, often seen in adults, is in a milder 
degree such mimicry of motion as is observed in dancing mania. 

Another element in the imposition of insanity by one upon another 
is the quality of the morbid mind-product. If a delusion, it must have 
an air of probability to the person receiving it, and must be gradually 
developed and imposed. It is because suspicion is inherent in the 
nature of most persons, because suspicion can wear so much probability 
of truth, that persecutory delusions are by far the most frequently 
adopted by others. Credulity is an important factor in the imposition 
of insane delusions upon others. It was the ready credulity of large 
numbers of persons, especially as regards religious subjects, that in 
the past led hundreds of thousands of people to adopt with faith the 
delusions of paranoiacs like John of Leyden, John Thorn of Canterbury, 
Joan of Arc, Richard Brothers, Joanna Southcott, John Brown, and 
many others, and actually to sacrifice their lives upon the altar of their 
beliefs. Though these delusions emanate from an insane person, their 
acceptance by others does not, of course, necessarily imply insanity in 
the latter, for delusions of this character have their support in the 
superstitions of many and in ignorance concerning supernatural matters. 
A persecutory delusion might be imposed by an insane person upon an 
intimate associate, and yet the latter need not, of necessity, be insane ; 
but when the exposed individual adopts the delusions, regulates his 
conduct upon them, allows them to become rooted in his mind, even 
begins to share the hallucinations of his friend, there is, of course, actual 
aberration of mind present. Several cases of folie a deux have come 
under my observation. One case was that of two sisters, aged about 
fifty to fifty-five, Irish, washerwomen, who, living alone in a tumble- 
down shanty, were often tormented by boys throwing stones at the 
house at night, and otherwise teasing them. They finally developed 
persecutory delusions with hallucinations, and both were very much 
alike. They became so violent in their demonstrations that ere long 
both were taken to the asylum, where I took charge of them. They 
were separated, the result being that one became rapidly demented and 
the other became a quiet worker, with fixed persecutory ideas and 
auditory hallucinations. 

Another pair of sisters, colored, between forty and fifty years of 
age, were similarly affected. For ten years one sister had been a para- 
noiac, with delusions of persecution by means of electricity, which 
was at all times, night and day, hurled through her body by a vast 
organization of conspirators. She had hallucinations of hearing. The 



726 MENTAL DISEASES. 

sisters had not lived together until within six months of my seeing them, 
the sane sister having recently become a widow. The sane sister grad- 
ually adopted the delusions of the insane one. and probablv the hallu- 
cinations. She believed her sister to be persecuted by an organized band 
of conspirators with electrical appliances. 

A third case was that of a husband and wife, who both became 
typical cases of melancholia, with, of course, similar delusions, one 
shortly after the other. Such a case as this might be called a coinci- 
dence, and not an imposed insanity. Probably grief over the insanity 
of the husband was one factor in developing that of the wife, but 
unconscious emotional imitation between two persons united bv special 
bonds of sympathy was undoubtedly another element. 

A fourth example I detailed fully some years ago in the " Alienist 
and Xeurologist " (" Paranoia in Two Sisters/ 3 January. 1890) : 

C. K. and H. K. were respectively thirty-six and forty-two years of 
age. teachers of music and singers by occupation, of German parentage, 
and had both been insane for some ten years. Their mother was a case 
of paranoia, with fixed delusions of an exalted religious nature. She 
believed herself to be the mother of God. She was never in an 
asylnm, but lived at home until her death. While insane she save 
birth to the younger of the two sisters. C. K. 

One of them wrote for me an autobiographical sketch, and the other 
some twenty-live letters, upon which the following facts in their identi- 
cal clinical history are based : 

The instigators of the conspiracy against them are chiefly their 
uncle, brother-in-law, and sister-in-law, and a brother has also been 
inveigled into it. By them are employed numerous detectives, expert 
chemists, and handicraftsmen, and. as they have privately hinted to me, 
also many lawyers. Openings are made in their rooms in spite of all 
they can do for the insufflation of noxious gases, smoke, camphorous, 
chloral, and chloroform vapors : and by some unseen agency substances 
are thrown at them which produce painful cutaneous eruptions. Their 
food and water and heating apparatus are tampered with for the intro- 
duction of poisons or to produce serious illness. They hear the 
mechanics at work upon the floors, walls, ceilings, and the voices of the 
detectives (hallucinations of hearing). Their food has a peculiar taste 
(hallucinations of taste). Most prominent of all are the singular 
odors of the room, of fruit and flowers sent them, of the water | hallu- 
cinations of smell). Sometimes they are black in the morning when 
they look in the mirror (illusion of sight). They are subject to remark- 
able, generally painful, sensations in their bodies (hallucinations and 
illusions of cutaneous sensibility). 

They hint of imaginary property in Germany, out of which they 
are being defrauded by relatives. For ten or twelve years they have 
been driven from one place to another in Brooklyn and New York by 
their pursuers. As yet they have sought only escape and protection 
from persecution : they have very rarely manifested anger by pounding 
the floor when hearing the mechanics at work or by complaint to the 



GENERAL ETIOLOGY OF INSANITY. 727 

landladies, and have not been brought to bay to a condition in which 
they might turn upon the actual instigators of the conspiracy and do 
them bodily harm. They have been on the point of a visit to police 
headquarters to make declaration against their enemies. 

From what I can learn of their history in youth the two girls 
differed from others of their age in a slight degree, some trifling eccen- 
tricities and some overweening self-consciousness constituting this 
difference. Thev have always been closely imited — living together, 
sleeping together, having the same affinities, talents, pleasures, and pur- 
suits. The development of suspicions and delusions of persecution had 
been so gradual that it did not become evident to others that they were 
actually insane until a comparatively recent period. When I first saw 
them in my office, they came heavily veiled, and, upon removing their 
veils, their faces were patched all over with small square pieces of 
cloth, covering sores. These were only an ordinary acne, made much 
worse by picking, by wearing wet cloths on their faces all night for the 
purpose of preventing poisonous vapors from entering their lungs, and 
by the removal of the strongly adhering pieces of linen from the bleed- 
ing surfaces. They healed up rapidly when I had prevailed upon them 
to make use of ung. zinci ox. freely. The face of the younger is par- 
ticularly characteristic of a degenerate type, one of its features being a 
disagreeable prognathism. 

Some of the skull diameters were pathological in character. One 
of the sisters died in convulsions from unknown cause, which the other 
sister still attributes to poison. The living sister still moves about from 
one part of the city to another, cherishing the paranoiac delusions, but 
supporting herself in part by teaching music. 



728 MENTAL DISEASES. 



CHAPTER III. 
GENERAL SYMPTOMATOLOGY OF INSANITY. 

Every psychic phenomenon is accompanied by a material process 
in the cortex of the brain. There is no insanity without disease of the 
cortex. The material disorder of the cortex is diffuse and partly 
organic, but mostly functional in character. We term it functional, for 
thus far our pathologico-anatomical and clinical studies have failed to 
reveal any definite material basis for the majority of psychoses. 

The progress made of late years in the study of physiological psy- 
chology has illuminated many obscure features of morbid psychology, 
and has put us in a position to better examine and classify the symp- 
toms of insanity. 

There are material processes in the central nervous system unaccom- 
panied by any parallel psychic process. The reflexes and automatic 
acts are examples. In these phenomena we observe a stimulus, a sen- 
sation, a movement. Movement paralleled by a psychic process be- 
comes action. We sometimes speak of conscious voluntary action. 
Action differs from simple movement in being accompanied by intercur- 
rent images — memory-pictures of former stimuli. A peripheral stimulus 
excites a cortical center, and is not carried at once to the motor region, 
but travels first by association fibers to the area in which are stored up 
residua of former similar stimulations, and later to the motor region. 
These residua of memory-pictures or ideas may be complex, constitute 
a series, have many associations, and hence we designate them as an 
idea-association. Action, therefore, consists of the series : stimulus, 
sensation, idea-association, movement. The various ideas thus excited 
tend to different motor expressions, so that the resulting movement or 
action will depend directly upon the strength of ideas. The stronger 
ones conquer. Ziehen, whose clear explication of the mental problems 
of psychiatry the writer closely follows, 1 has well described idea-asso- 
ciation as the play or battle of motives. He gives the following exam- 
ple of the physical and psychic processes just described : 

I see a rose in a strange garden (stimulus and sensation). A long 
series of ideas is aroused by the stimulus and the visual sensation of 
the flower (idea-association). For instance, the memory of the rose's 
fragrance comes to mind, then I think how well it would look in my 
room, that it is the property of another, that plucking it would be 
punishable, and so on. Only after the whole series of presentations has 
passed before the mind does action follow, and whether I pluck the 
flower or go my way without it will depend upon the strength and 
intensity of the conquering idea. 

Every psychic process must be regarded upon the basis of such a 

1 "Psychiatrie," Th. Ziehen, Berlin, 1894. 



GENERAL SYMPTOMATOLOGY OF INSANITY. 729 

scheme, and as accompanied by its material parallel (progress from the 
sensory cells to the idea-cells, and from these to motor-cells by means 
of association-fibers). 

Sometimes the idea of movement (memories of former sensations of 
movement) comes before the movement in the series just described, but 
generally the movement is perceived after it has taken place by means 
of the sensation of the movement. 

There are really but two psychological elements — viz., sensation and 
idea. The only process connected with these elements is the idea- 
association. Their product is action. The so-called mental powers of 
old-time psychology do not exist. The assumption of a special power 
of will dominating the idea-association and voluntarily determining this 
or that movement is particularly superfluous and misleading. The 
assumption of a special power of apperception which turns its " atten- 
tion " voluntarily upon this or that idea or sensation to determine the 
course of the idea-association is equally superfluous. 

The presentations or ideas rather follow one another according to laws 
without intervention of any especial voluntary power of the mind, and 
the final movement or action is the necessary result of association of 
these presentations or ideas. Finally, there exists no particular faculty 
of feeling, for exact investigation demonstrates that our feelings of 
what is agreeable and what is distasteful, of pleasure and pain, appear 
never in an isolated state, but always combined with sensation and idea 
as attributes or properties. 1 

Following Ziehen in these particulars, we shall study pathological 
psychological processes on the basis of the scheme just described, and 
in each case investigate, first, disorders of sensation ; then, disorders of 
the memory-pictures, presentations, or ideas ; then, again, disturbances 
of the idea-association ; and, finally, the influence of these disturbances 
upon the actions or conduct of the patient. 



DISORDERS OF SENSATION. 

Sensation is the first element in the psychic process. It is deter- 
mined by some external stimulus affecting any sensory nerve. Every 
sensation has four important attributes — viz., quality, intensity, tone (the 
accompanying feeling of pleasure or pain), and space-projection. We 
are not especially concerned with the last in morbid psychology. 

Qualitative Disorders of Sensation. — The two important classes 
of qualitative disorders of sensation are hallucinations (in which we have 
sensation without external stimulus) and illusions (in which we have the 
external stimulus, but a transformed or perverted sensation). An ex- 
ternal stimulus to a peripheral nerve is carried to the cortex, where it 
acts as a secondary stimulus in exciting sensation. 

Hallucinations. — A hallucination is a sensory impression without 
external stimulus. It is often also defined as a perception without an 

1 " Leitfaden der physiologischen Psychologie," von Th. Ziehen. Jena, 1893. 



730 MENTAL DISEASES. 

object. The patient hears voices where all is silent, sees forms and 
figures in empty space. 

Hallucinations of sight are very common, and vary from the simplest 
sparks, lights, shimmers, flames, spots, threads, clouds, and shadows to 
the most complicated groups of persons and landscapes with perfect 
details. Sometimes they are colorless, like silhouettes ; sometimes radi- 
ant and fantastic with color. Sometimes they are flat, like pictures ; 
sometimes plastic. Ordinarily, the forms and objects observed are of 
natural size, but occasionally they are gigantic or diminutive. They 
may appear close at hand or far away. They may be quiet or full of 
movement, like the zooscopic hallucinations of alcoholism. Rarely, 
real objects are doubled or multiplied (hallucinatory diplopia and poly- 
opia). Real objects are sometimes concealed by the hallucinations, 
sometimes merely diaphanously veiled. Hallucinations may fill the 
whole field of vision or appear in homonymous half-fields, as in the 
hemiopic hallucinations described by the writer in cases of insanity and 
of homonymous hemianopsia. 

Hallucinations of hearing are also extremely frequent, and vary 
from simple sounds, tinnitus aurium, rushing, roaring, whispering, 
tinkling, to complicated music and words and sentences. These last 
may be in natural tone or deep- voiced, whispered or loud ; may be the 
voice of one or many persons ; may be pronounced in various languages ; 
may be single words or long orations ; may seem near at hand or far 
removed ; and may be heard in one ear, though usually in both. Not 
infrequently the voice seems to the patient so near that it appears to be 
in his head or body. 

Hallucinations of common cutaneous sensibility may appear any- 
where in the skin or in mucous membranes in the form of electric 
shocks, pricking, tingling, blows, caresses, sensations of heat or cold, 
indignities to the sexual organs (feeling of cohabitation), etc. 

Hallucinations of smell are very common. The patients perceive 
odors of chloroform, sulphur, noxious gases, smoke, filth, or, on the 
other hand, the smell of perfumes and flowers. 

Hallucinations of taste are so generally combined with those of 
smell, because of the close physiological relation of the two senses, that 
true hallucinations of the primary elements of taste (salt, sweet, bitter, 
and sour) are uncommonly rare. A hallucination of a bitter taste is 
the most frequent. On the other hand, the combined hallucination of 
taste and smell (as of blood, filth, etc.) is rather common. 

Hallucinations of organic sensation are not rare. The patients com- 
plain of peculiar or extraordinary feelings in various organs, such as 
malposition, gnawing, cutting, pain, etc. 

Hallucinations of active or passive movement of the body or its 
parts depend probably chiefly upon disorders of joint sensibility. The 
patients feel themselves lifted in the air, floating, the limbs moved 
actively, the head turned to one side ; or, the sensation of movement of 
the muscles required for speech may give rise to the hallucination of 
having spoken a word or sentence. 



GENERAL SYMPTOMATOLOGY OF LNSANITY. 731 

Various hallucinations are often associated in such a manner as to 
render the hallucinated objects still more natural and deceptive, though 
more frequently they are not thus commingled. Thus, visionary 
figures may speak or be dumb, and the fancied voices may come from 
visually projected or from unseen persons. Sometimes vision, hearing, 
and cutaneous sensation may be combined to give reality to the object. 
Combinations of others are also met with, and, indeed, these mixed 
hallucinations are common and multiform. 

As regards the development of hallucinations, some are doubtless 
peripheral, but the majority are central in their origin. Disorders of 
the eye, ear, nasal cavity, mouth, mucous membranes, skin, and viscera 
may give rise to hallucinations, though they are more commonly the 
cause of illusions. Hallucinations are never new creations, but are made 
up of memory-pictures stored up in the cortex ; these may, however, 
make their appearance in new combinations. The congenitally blind 
never have visual hallucinations ; the congenitally deaf never auditory 
hallucinations, though they are noted in acquired blindness and deaf- 
ness. 

Hallucinations are usually of two kinds — those which have to do 
with the ideas presented in the mind at the time of their manifestations, 
and those which are concerned with latent memory-pictures. The 
former are more common, but both may be observed in the same 
patient. The first kind are those which the patient describes as 
visions which picture his very ideas, and voices which read off his 
thoughts as fast as they can come into his mind — indeed, often appar- 
ently before he thinks them. The second class of hallucinations often 
astounds the patient by association with things long past and quite 
forgotten. 

We are taught by physiological psychology that a stimulus to the 
eye arouses a sensation in the occipital lobe, to the ear a sensation in the 
temporal lobe, and so on, the sensation further exciting an image which 
remains as a memory-impression. All normal sensations, then, depend 
upon the series stimulus, sensation, memory-picture, or idea. Now, 
hallucinations are always cortical, as regards localization, and depend 
upon a reversal of the normal course just described, and without the 
stimulus. The memorv-imaffe is excited and then excites the sensation. 
A certain irritability of these centers will be induced, undoubtedly, 
by morbid processes in the peripheral nerves or their terminations, 
such as entoptic or entotic processes, which will render them all the 
more excitable, since external stimulus is not then altogether wanting. 
Finding such, — and we should always investigate carefully for a periph- 
eral physical basis, — the dividing-line between hallucinations and illu- 
sions becomes less distinct. Naturally, the normal mind recognizes the 
real nature of muscae volitantes, tinnitus aurium, neuralgic pains, etc., 
and it is only the abnormal mind which employs them as material for 
illusions and hallucinations. 

In the examination of a patient we must determine the presence of 
hallucinations and the effect of their presence on idea-association. One 



732 MENTAL DISEASES. 

must not mistake actual occurrences described by the patient, nor the 
events of dreams confused by him with events of waking, nor ordinary 
illusions for hallucinations. There is danger, too, of overlooking their 
presence. Patients conceal them, conscious that the hallucinations are 
morbid, or knowing that they will be looked upon as such, but will 
often write about them or tell of them to other patients if opportunity 
be given. Very often the physician is enabled to recognize their exist- 
ence from the expression and conduct of the patient. 

As regards the influence of hallucinations upon the course of idea- 
association, the most important question is whether they are regarded 
by the patient as real sensations or not. He treats them as actual 
phenomena, as if they were normal sensations, or he distinguishes them 
from his ordinary sensations as peculiar, novel, and possibly inspired by 
supernatural agencies ; or he is really conscious of their morbidity, but 
may believe them to be induced by enemies by means of poison. If the 
hallucinations are faint and transitory, the patient may not be much in- 
fluenced by them ; if they are marked and persistent for a long period, 
he ultimately loses his critical faculty and comes to believe in their 
reality. Such being the case, his thought and conduct are bound to be 
influenced by them, and more powerfully influenced than by normal 
sensations, or by any reasonable consideration or argument. Hallucina- 
tions either inhibit (hallucinatory stupor) or retard (hallucinatory con- 
fusion) the idea-association ; or they induce direct intrinsic delusions (as 
when a voice cries " Thou art God," and the patient immediately be- 
lieves himself to be God). The actions and conduct of a patient are 
very much influenced, and in multiform ways, by hallucinations. He 
has the expression of listening, or stares apparently at nothing. He 
closes his ears, covers his eyes or head, closes up cracks and openings, 
or listens at the window or keyholes. He refuses or spits out his food. 
He holds his nose, or suddenly closes the window to prevent the entrance 
of noxious gases. He turns his head, runs, shouts, lifts his arm quickly, 
or takes peculiar attitudes, acting upon a hallucination of muscular 
sense (imperative movements, imperative speech, imperative attitudes). 
The imperative attitudes may be very persistent and long-continued, and 
are then called catatonic. Hallucinations often lead to imperative acts 
which may be of a violent nature. If hallucinations are innumerable, 
very changeable, and intense, the patient is affected by so-called hallu- 
cinatory agitation. 

Hallucinations are so extremely rare under normal conditions that 
they are to be considered as almost always pathological. Illusions are 
rather common in the normal mind. True hallucinations may occur in 
apparently normal individuals, but examination will show that such 
persons are neurotic by heredity, and that some stress of mind or body 
has induced this psychopathic phenomenon. This is particularly true 
in childhood. 

Outside of the psychoses, hallucinations are met with in toxic states, 
fevers, cachectic conditions, sun-stroke, and some of the neuroses (epi- 
lepsy, chorea, hysteria). A hallucination of any sense may be the aura 
of an epileptic attack ; sometimes, when visual, it may be hemiopic. 



GENERAL SYMPTOMATOLOGY OF INSANITY. 733 

Hallucinations are the chief symptom of one form of paranoia. 
Other psychoses, such as mania and melancholia, manifest them only 
exceptionally ; while still others, like senile and paretic dementia, pre- 
sent hallucinations, it is true, but not in such prominence as to make 
them a characteristic symptom. Visual hallucinations are more com- 
mon in acute than in chronic psychoses, and they are seldom indepen- 
dent of hallucinations of feeling and hearing. Auditory hallucinations, 
on the other hand, are more characteristic of chronic types of mental 
disorder, and are often observed alone. 

The close union of the auditory center with the motor speech center 
gives a peculiar interest to hallucinations of hearing. From infancy 
man is trained to think to a great extent in word-images or speech- 
images, and thinking is, therefore, nearly always associated with some 
stimulation of the speech-muscle centers in the brain. Therefore, hal- 
lucinatory irritation in the auditory area of the brain causes synchronous 
irradiation to the motor speech center, and words and sentences are 
heard by the hallucinant as if projected into the external world, or into 
some part of the patient's body (head, throat, chest, stomach, or even 
extremities). The stimulation of the speech muscles, however feeble, 
may be sufficiently strong to induce recurrent sensations of movement 
in them, which leads the patient to imagine that his thoughts are being 
read off internally by the voice, and sometimes repeated apparently 
before the thought has fully developed in his brain. 

Illusions. — An illusion is a false perception. There is a stimulus 
but a perverted sensation, a wrong interpretation. The sensation 
corresponds only in part to the stimulus. A patient hears the rain 
falling, but perceives it as music ; he sees the bedpost, but imagines it 
a ghost. 

Visual illusions exhibit a transformation of form, or color, or both. 
This is often favored by indistinctness of outline, as when it is half dark 
or there is a shimmering, nickering light. But often clear outlines are 
transformed. The patient may see the familiar faces about him changed 
into those of strangers, transformed by grimaces, or deathly pale. A 
sharp distinction between illusory transformation and actual hallucina- 
tion is often difficult to draw. It is peculiar to illusions that they not 
infrequently present objects as distorted and diminished or increased in 
size. This is especially true among epileptics. AVhen this is noted 
with all objects, it often depends upon entoptic disorders. Thus, meta- 
morphopsia may arise from astigmatism and retinal disease, micropsia 
from paresis of accommodation, and macropsia from spasm of accommo- 
dation. "When this is not the cause, perverted association of the sensa- 
tion, with disordered muscular sense, may play a role. Sometimes, 
though rarely, the illusion may consist of a perversion of color analogous, 
for instance, to the yellow appearance of objects in santonin-poisoning 
(due to violet blindness induced by the poison) or to red vision (ery- 
thropsia induced by fatigue of the retina for the short-waved rays of the 
violet side of the spectrum). 

Illusions of hearing consist mostlv of the construction of words out 
of inarticulate sounds, or of the misinterpretation of the words or 



734 MENTAL DISEASES. 

sentences spoken in the patient's hearing. He may transform them into 
mocking, indecent, derogatory, or flattering words. 

Illusions of common sensibility are, perhaps, more important in 
insanity than hallucinations of this sense. But they are difficult to 
study and establish. It is probable that the sandy, earthy taste of food 
often complained of by patients is more an illusion of touch than of taste. 

Illusions of smell and taste are, in the main, unpleasant in character 
and are more common than hallucinations of these senses. 

Illusions of organic sensation are frequently noted, and consist of such 
sensory metamorphoses, for instance, as the mistaking of intestinal 
motions for pregnancy, and the feeling of diminution or increase in size 
of various organs (particularly noticeable in epilepsy and paresis). 

Illusions of muscular sense or of movement are rare. 

Illusions, like hallucinations, may form their material from the 
concepts at the moment in consciousness, or from latent memory -pictures. 

The theory of the cause of illusions is analogous to that of hallucina- 
tions. They arise from a pathological recurrent influence of the excited 
memory-picture cells upon the sensory cells. The difference lies in the 
association, also, of an actual external stimulus which undergoes trans- 
formation. 

Illusions are much more common than hallucinations, and are not 
seldom met with in normal persons. Often they are difficult to dis- 
tinguish from one another. Sometimes it is impossible to differentiate 
true illusions from so-called illusionary judgments, in which we are 
concerned not so much with a transformation of sensation, as with an 
erroneous judgment of the character of a normal sensation. 

Illusions are noted in all forms of psychoses, especially in acute 
forms. They are particularly noteworthy in the hallucinatory form of 
paranoia. 

Disorders of Intensity of Sensation. — These consist of hypesthe- 
sias, anesthesias, and hyperesthesias. Hypesthesias and anesthesias are 
observed in various psychoses which are complicated by such disorders 
as hysteria, chorea, multiple neuritis, tabes, focal cerebral lesions, etc. 
Hyperesthesia is also encountered in complicating disorders, such as hys- 
teria, tubercular meningitis, neurasthenia ; but is also often noted in the 
prodromal stages of many acute psychoses. It is especially remarkable 
in the insanities of childhood. A valuable objective sign of hyper- 
esthesia is exaggeration of the superficial reflexes. 

Disorders of Sensory Tone. — Agreeable or disagreeable feeling, 
associated with sensation, is described as sensory tone. Sensory tone may 
be perverted in insanity so that, for instance, fragrance is perceived as 
unpleasant, dissonance as pleasant, and vice versa. One notes such per- 
versions in the slight psychopathic conditions of pregnancy in the form 
of capricious tastes and appetites. Homosexual perversion is a form of 
this disorder manifested in the domain of sexual sensation. Pathologi- 
cal disorders of the intensity of sensory tone consist of hypalgesia and 
analgesia, hyperalgesia, hyphedonia, and hyperhedonia. 

The hypalgesias are noted in hysteria, tabes, congenital and acquired 
mental deficiency, and in severe hallucinatory confusion. 



GENERAL SYMPTOMATOLOGY OF INSANITY. 735 

Hyperalgesia is observed under the same circumstances as hyper- 
esthesia. It is most often seen in hysterical and neurasthenic insanities, 
and almost exceptionally at certain points (such as the supraorbital, 
infraorbital, mental, Valleix, iliac, intercostal, mammary, vertebral, and 
cranial suture points) pressure elicits pain. The pain of hunger, which 
leads in many psychoses to pathological hunger (bulimia) belongs in 
this category. 

Hyphedonia is a morbid diminution of the feeling of pleasure in any 
sensory perception. It is more important in the domain of sexual sen- 
sations than in others, where it may reach the degree of anhedonia. 
Sexual anhedonia is not uncommonly developed on the basis of a seri- 
ous hereditary degeneracy, and is frequent, too, in organic disease of 
the central nervous system (tabes and paresis), as well as in toxic con- 
ditions (alcohol, cocain, morphin). Hyphedonia, in connection with 
hunger sensations, may reach the state of complete psychic anorexia in 
some insanities. 

Hyperhedonia is a morbid increase of positive sensory tone (agree- 
ability of sensation), and is noted most often in relation to sexual 
sensations. 

Disorders of Memory-pictures or Ideas. — Every stimulus in 
arousing a sensation in the cerebral cortex leaves some material vestige 
or impression, which remains as a latent memory-image or picture, 
latent presentation, or idea. Countless numbers of memory-pictures left 
by innumerable sensations of all kinds are stored away as a material 
deposit in the brain-cortex. These are rearoused either by the same or 
a similar stimulus, or excited through the stimulus of some idea- 
association. Only a few of the millions of memory-pictures are 
awakened to life at any one moment ; all of the others remain latent. 
The general concept of any particular object is made up of the associa- 
tion of many centers in the brain, some of which are far apart, such as 
the smell, feel, taste, color, sound, and name of the object. The rela- 
tion of this object to others of its kind is present in other associations, 
and these again in others, so that the material basis of an idea must be 
a perfect network of association fibers ; and all of this labyrinth is con- 
nected with the complex series of language-centers, but particularly 
with the motor and auditory speech-centers, which are trained up from 
earliest infancy to associate the spoken word with the concrete concep- 
tion. A word, therefore, expresses, like an algebraic x, y, or z, some 
very intricate and complicated formula. Take words like "home," 
" right," " wrong/' and so on, and think what a countless number of 
associated memory-pictures each one must represent ! Words are 
simply convenient abbreviations which render more easy the use of con- 
cepts in idea-associations. 

TTe distinguish in every idea four cardinal properties : (1) The con- 
tents or meaning ; (2) distinctness ; (3) associated affects ; (4) energy 
or intensity. 

The pathological disturbances of ideas may be studied under the 
headings of disorders of their evolution, durability, concomitant affects 
and associations. 



736 MENTAL DISEASES. 

Defective Evolution of Ideas. — The number of concepts stored up 
in the brain varies enormously under normal conditions with individuals 
and races. In morbid psychology we find the number of ideas extremely 
small among congenital defectives, such as the idiot, the imbecile, and 
the feeble-minded. The idiot may preserve rudimentary memory- 
pictures of the simplest things, such as food and eating, light, dark- 
ness, clothing, but without speech associations ; he will have none of 
other persons or other objects about him. In the imbecile the concepts 
are more numerous and may be known by name ; he recognizes persons 
and objects, distinguishes simple colors with difficulty, may have 
number concepts as high as ten ; he has a few concrete ideas, but, as a 
rule, no abstract ideas. The feeble-minded has a larger number of 
memory-pictures, may have abstract ideas, recognizes the significance of 
likeness and similarity, and may use the words God, right, wrong, etc., 
but in reality be unable to tell the meaning of such complex, abstract 
conceptions. It is necessary, therefore, to avoid concluding that the 
idea is present because the word is spoken by such a patient, for it is 
particularly characteristic of the congenitally feeble-minded to be apt 
with words while deficient in grasp of their meaning. 

Disorders in Durability of Memory-pictures. — The forgetting of 
a memory-picture, when the stimulus and sensation producing it are not 
repeated, may be considered to be due to its gradual erasure by the in- 
fluence of the nutritive processes which affect the cortical ganglion-cells 
equally with all the elements and tissues of the body. This physio- 
logical destruction of the memory-picture is always very slow, but by 
pathological processes may be rendered enormously rapid. The de- 
struction may be diffuse or limited to one sensory sphere (for example, 
apraxia, where the sensory ideas of objects are lost, though the sensory 
apparatus may be intact ; mind-blindness, word-blindness, mind-deaf- 
ness, word-deafness, etc.). But these limited defects of memory-pictures 
are due to focal lesions in the brain, and do not concern the alienist so much 
as the diffuse destruction of ideas, although it is true that the latter may 
sometimes be a sequel to a circumscribed lesion, and, on the other hand, 
that the diffuse disorder may, as in general paralysis, sometimes affect 
one region more than another. A loss of concrete ideas, such as general 
concepts of relationship, etc., which are represented by a wide-spread 
association network in the whole cortex, can only be caused by a diffuse, 
far-reaching disturbance. We see examples of such loss in the acquired 
dementias of paresis, epilepsy, and senility, dementias secondary to 
acute psychoses, and dementias due to toxic agents. It is natural that 
the latest memory acquisitions should be lost first, and the older mem- 
ories successively later, in direct proportions to their age, according to 
a certain " law of regression," as Ribot terms it. This is to be ex- 
plained by the want of permanence and stability in the newest arrange- 
ment or concatenation of protoplasmic molecules and ganglion-cells. 
The older impressions have become more fixed and durable. 

Since an experience leaves behind not alone a single memory-picture, 
but a whole series arranged in chronological order, we may, as in am- 
nesias, find pathological states in which there are losses of such series 
of ideas during a definite period of time. The so-called subconscious 



GENERAL SYMPTOMATOLOGY OF INSANITY. 737 

or unconscious states are examples of this phenomenon. They are 
observed in epilepsy, intoxications, hysteria, narcolepsy, hypnotism, 
somnambulism, injuries to the head, and in transitory insanity. 

Affective Disorders. — Pleasurable or disagreeable feelings accom- 
pany ideas, just as they do common sensations ; so that there is an intel- 
lectual affective tone analogous to sensory tone. If two ideas be pre- 
sented simultaneously, and if one of these have a stronger emotional 
quality than the other, the tone of this will be irradiated to the other. 
Ziehen, in describing irradiation, gives the following example : "If I have 
met with an accident in any place, afterward not only is the memory of 
the injury accompanied by an unpleasant feeling, but the memory of 
the place is likewise mingled with a disagreeable affect. Furthermore, 
when I again see the spot where the accident occurred, I may feel again 
the sensation of the injury, accompanied by its unpleasant sensory tone." 
Here the memory-picture arouses the sensory tone of the sensation ex- 
perienced. This is termed reflected tone. The most important conse- 
quence of the laws of emotional irradiation and reflection is that if in a 
certain period of time one or several sensations and ideas have a strong 
and similar emotional tone, all other sensations and ideas presented to 
the mind during the same period of time will be colored by the tone of 
the former. Such irradiation creates our moods, which are hence the 
abstract or summary of the similar emotional tones of the ideas and 
sensations experienced within any definite period of time. 

Moods and emotions influence strongly the flow of our ideas, and, as 
a consequence, our actions. Depressed moods or affects inhibit, while 
exalted affects increase the flow of ideas, and likewise the resultant 
actions. Depressed affects are more durable and persistent than exalted 
affects. The latter subside rapidly. The more complicated ideas, such 
as justice, honor, law, family, patriotism, etc., are accompanied by a 
specific affect or tone which we designate as ethical feeling. Ethical 
feeling is the result of numerous irradiations, which the single idea 
acquires from all of the ideas associated with it ; and the sum of the 
ethical feelings of an individual gives him his character (Ziehen). 

In morbid psychology we classify changes in the affects as patho- 
logical depression, exaltation, irritability, apathy, and mutability. 

Depression. — Depression is observed in many forms of insanity, 
particularly as a prodrome, but is characteristic of the melancholy types. 
It is a very common prodrome of acute mania, and a long period of 
morbid depression is frequently noted as an antecedent in general 
paresis. It is observed in neurasthenia, in hypochondriasis, and not 
seldom as an interlude in any psychosis. It is the cardinal symptom 
of melancholia. Depression is a normal consequence or accompaniment 
of sorrowful or dreadful hallucinations and ideas, and is, under such 
conditions, termed secondary. It is primary depression with which we 
are more concerned in insanity — a depression not at all or but slightly 
motived by such hallucinations and ideas as we have just described, 
but a mood which takes possession of the mind of the patient and gives 
its own original color to every thought arising in his mind and to every 
external object presented to his consciousness. Past, present, and 
future are alike under the shadow of this mood. When mild in degree, 
47 



738 MENTAL DISEASES. 

the patient feels only an inexplicable sadness — a certain restlessness or 
state of worry ; but when extreme, this general mood of sadness be- 
comes a condition of pathological anxiety — a mixed feeling of grief and 
dread, often accompanied by a feeling of suffocation or pain about the 
heart, and, therefore, frequently designated as " precordial anxiety " or 
" precordial fright." When primary depression is present, the patient 
feels the change in his mental condition, observes that he no longer is 
cheered by the usual pleasant events of his daily life, that these rather 
intensify his misery. The affection and sympathy of his friends and 
family either awaken no response in his own breast when he tends to 
believe that he has lost all natural feeling, or they may awaken sus- 
picion, dislike, and distrust. The inhibition of the flow of thought 
restricts his ideas to himself and to the somber contents of his mind. 
He is not easily distracted from such contemplation, and answers ques- 
tions, if at all, very slowly and with great difficulty. Nearly all cases 
with morbid depression complain of disorders of visceral sensibility, 
from a slight sense of constriction at the throat to precordial distress, 
from a general feeling of illness and uneasiness to a feeling of extreme 
and general restlessness. No doubt depression influences often the 
entire musculature of the body, so that the patient wrings his hands, 
picks his fingers or head, walks up and down, is extremely agitated, 
goes into a condition of catalepsy or catatonia, or, on the other hand, 
remains absolutely immobile and requires the service of others for every 
movement. The muscles of the peripheral arteries contract and in- 
crease the frequency of the heart's action. The constriction of the 
throat is probably an actual contraction of the esophageal muscles. 
Precordial anxiety is most likely due to vasomotor disturbance in the 
vessels of the heart. The constipation so frequent in depressed con- 
ditions depends doubtless upon retardation of peristalsis. Thus we 
observe in one case motor inhibition, in another motor excitement, and 
in some alternations between the two. 

In seeking to explain the mood of sadness and uneasiness which he 
feels, the patient tends to develop delusions. He invokes the first ideas 
which would naturally come to him under such circumstances. He 
seeks in his past life for some sin, the commission of which may have 
brought this punishment. He magnifies some trivial error in his youth 
into an unpardonable sin. Or he comes to think that poverty stares 
him in the face, or that he can never recover from an incurable illness 
which has taken possession of him. Occasionally, a persecutory delusion 
is evolved from a primary depression. 

Exaltation. — Exaltation is occasionally noted as an intercurrent 
symptom in any psychosis. It sometimes alternates with depression, 
forming a constant cycle, as in circular insanity, and sometimes it pre- 
sents itself during convalescence from melancholia as a reactive phe- 
nomenon. In the majority of cases of general paresis a period of 
exaltation develops. In maniacal states, however, it is observed as a 
cardinal symptom. As with depression, we distinguish a secondary 
exaltation consequent upon agreeable hallucinations and ideas, and a 
primary or unmotived exaltation. In exalted moods the somesthetic 
sensations are pleasurable and give rise to feelings of perfect health. 



GENERAL SYMPTOMATOLOGY OF INSANITY. 739 

strength, and vitality. The stream of ideas is hastened, and as a 
result the patient becomes, according to the degree of exaltation, talka- 
tive and garrulous, or exhibits a veritable logorrhea, — a constant, rapid 
flow of words, — which may often assume a rhyming, singing, or orator- 
ical character, with marked incoherence. The rapid stream of presen- 
tations is paralleled in the motor sphere by increased muscular activity, 
varying from busy occupation with nothing to gesticulating, grimacing, 
and dancing, and to the wildest and most violent motor excitement. 

Primary exaltation frequently gives rise to delusions of a grandiose 
character, though these are unstable and fleeting, corresponding to the 
rapidity of change in the contents of consciousness. But the feeling 
of well-being and of egotism which makes up the fundamental mood 
of the exalted patient leads him to be extremely impatient of any 
restraint of his activities ; and, in consequence of this, the reactive feel- 
ing of aggressive anger and fury is easily aroused, leading to acts of 
violence and destruction. 

Irritability. — Irritability is a condition which has to do chiefly with 
the affects of anger and rage. While observed in association with 
exaltation, as just noted, and among the prodromata of various insani- 
ties, it is particularly characteristic as a primary emotional state of 
congenital and acquired mental weakness, neurasthenic insanity, and the 
epileptic psychoses. In the latter it not infrequently becomes a true 
furor epilepticus. Irritability is occasionally noted in the convalescence 
from acute insanities, sometimes conjoined with a peculiar tearfulness, 
a lacrymose irritability. "While most of the affects of both depres- 
sion and exaltation are concerned with the ego, the affect of anger 
differs markedly from these in that it has to do with persons or objects 
outside of one's self. At the same time anger is a depressed emotion, 
but with certain peculiarities. In its influence upon the flow of ideas 
and upon action it first retards or inhibits, but finally, by an accumula- 
tion of stimuli, induces a sudden motor explosion, which may vary from 
simple aggressiveness to the most uncontrollable fury. Abbreviation 
of the usual play of motives is characteristic of the motor explosions 
of anger and fury. The sensory stimulus is carried directly into the 
motor areas, without the intervention of ideas or inhibitions, which 
accounts for the frequent occurrence of outbreaks of violence and 
destructiveness, followed by complete or partial amnesia as to the acts 
perpetrated. 

Diminution or cessation of sensory and intellectual emotional tone 
gives rise to the condition known as partial or general apathy. A 
general apathy is frequently observed in neurasthenic insanity and in 
stuporous states, but it is more common in certain cases of melancholia. 
Such patients will complain, paradoxically as it may seem, of a painful 
feeling of having lost all feeling. They say that they feel no affection 
for their children, no hope of getting well, no pleasure in anything, no 
grief at the loss of friends, that their hearts are turned to stone. 
Sometimes ordinary sensory feeling seems absent also, and they say 
they can feel neither heat nor cold, nor the pain of a cut or injury. 
One must distinguish between an apparent apathy and a want of atten- 



740 MENTAL DISEASES. 

tion consequent upon self-centering of the thoughts on strong delusions 
and hallucinations. 

Partial apathy or limited defects of the emotions, as well as of 
special and ordinary sensation, are frequently encountered in various 
grades of congenital idiocy and acquired mental weakness. Defects of 
the higher forms of intellectual sensory tone, the ethical feelings, which 
we meet with in some of these cases, constitute the so-called moral in- 
sanity. 

In certain psychoses a general apathy may be so great and the hori- 
zon of intellectual processes so narrowed that the condition amounts to 
a pseudodementia (Magnan), though there is truly no actual defect of 
intelligence, the mental functions being merely temporarily inhibited or 
suspended. 

A peculiar mutability or lability of affects is not an infrequent phe- 
nomenon in insanity. Laughing and crying at the same time is not a 
rarity in persons who are not insane, being the result of the com- 
mingling of pleasant and distressing ideas present at the same moment 
in consciousness. The emotional pendulum swings quickly from one 
extreme to the other. Such disequilibration is particularly character- 
istic of hysteria, and is notable in the hysterical psychoses. But irri- 
tability and rapid alternation of cheerful and pathetic affects are also 
encountered in the most various psychoses. The chronic melancholiac 
with his sad face and automatically repeating his set phrase, " I am 
going to be killed," may laugh out suddenly at a funny incident and 
immediately relapse into his habitual mental attitude. In the same 
manner the paranoiac may forget momentarily his persecutory delusion. 
In general paresis this swinging from one emotion to the other in the 
most rapid manner is extremely characteristic. Mutability of affects is 
indeed most common in combination with conditions of intellectual de- 
fect or mental weakness. 



DISORDERS OF THE IDEA-ASSOCIATIONS. 

An idea-association is a psychological series, beginning with a stim- 
ulus and ending with a movement, between which may be one or two 
or more memory-pictures, some coming into consciousness, others re- 
maining latent, but all associated by the nerve-fibers running between 
the ganglion-cells of the cortex in which are deposited the sensory 
impressions. The selection and serial course of ideas in the stream of 
thought are determined by fixed laws. One of these is the law of simi- 
larity-association — i. c, a sensation induces an idea (seeing a flower gives 
the idea of a flower) and another latent idea is aroused by this (a rose) 
because the second memory-picture has marked similarity to the first 
idea — the rose is remembered or recognized. Every recognition contains 
a judgment, since a new sensation is seen to be like a former sensation. 

Another law is that of simultaneity of reception — i. e., memory-pic- 
tures are associated when their sensory stimuli have been received at the 
same time. For example, the sight of a friend recalls the city, the 
street, the house where one first saw him, and many others in a highly 



GENERAL SYMPTOMATOLOGY OF INSANITY. 741 

complex series of associations. Not all of these, however, will arise at 
sight of him. Perhaps it may be one or two, perhaps others ; so that 
another factor arises — viz., the degree of associative relationship. Still 
another factor is the feeling (the intellectual sensory tone, the affect) 
combined with each of the memory-pictures. Those memory-pictures 
will rise soonest into consciousness which are combined with the live- 
liest emotions, agreeable or disagreeable, pleasant or painful. Ideas 
with strong affects have a greater chance in the conflict of ideas to rise 
up from their latency into consciousness. Still another feature of this 
scheme is that the latent ideas with their numerous associations influ- 
ence one another reciprocally, some to excite and some to suppress or 
inhibit. While simpler ideas are arranged in a sort of serial association 
one after the other, on a higher plane the successive memory-pictures 
are bound together into judgments and conclusions. Ziehen cites the 
example of the simple judgment, " The rose is beautiful," in which we 
have not these ideas discreetly ranged one after the other, but the ideas 
"rose," " is," and "beautiful" stand in a thorough relation to one 
another. This form of idea-association is designated as a judgment-asso- 
ciation. 

The normal stream of ideas, or idea-association, has a definite swift- 
ness which varies in different individuals and in the same individual at 
different times. In psychopathology we learn that agreeable or pleasant 
affects hasten and disagreeable or unpleasant affects retard the flow of 
thoughts. 

The pathological disorders of the idea-association are to be classified 
as follows : 

1. Disorders of memory. 

2. Disorders of attention. 

3. Accelerated flow of ideas. 

4. Diminished flow of ideas. 

5. Disturbance of the connections between the ideas of the idea- 
association (incoherence). 

6. Falsification of the judgment-associations (delusions and impera- 
tive ideas). 

7. Defective judgment-associations (weakness of judgment). 
Disorders of Memory. — Recollection according to the principle of 

similarity-association is the calling up (by a sensation) of a memory- 
picture of earlier, similar, or identical sensations. 

Recollection is disordered or destroyed by loss of the necessary 
memory-pictures, by any general marked retardation of cortical associa- 
tions, and by dissociation of the idea-association. 

Dissociation is equivalent to incoherence, and when a general inco- 
herence exists, disorder of recollection is the rule. The patient then 
confounds persons and objects, and often loses the ideas of place and 
time (a condition for which disorientation is the best name). The 
peculiar paramnesia observed in alcoholic psychoses, especially in the 
delirium accompanying alcoholic neuritis, is a striking example of this 
loss of orientation. The mistaking or confounding of persons and 
things depends upon illusions, delusions, incoherence of ideas, lack of 
distinctness of the requisite memory-pictures, or, finally, upon voluntary 



742 MENTAL DISEASES. 

caprices of the patient. In alcoholic paranoia and epileptic insanities, 
and sometimes in other psychoses, we encounter the so-called " halluci- 
nations of memory" — a bad term for the phenomenon experienced some- 
times by normal individuals, of having seen this or that thing, or of 
having been in the same place before, although in fact the object and 
place are absolutely new. 

From the practical standpoint it is wise to investigate two conditions 
in relation to memory: first, the memory-store, made up of all past ex- 
perience; and, secondly, the patient's power of adding new experiences to 
this memory-store (power of retention, merkfdhigkeit) . Amnesia is a 
defect in the memory-store, often sharply circumscribed as to time- 
relations by some trauma, accident, emotional shock, or fit (a classic 
symptom, for instance, in epilepsy). Amnesia may be total or partial. 
The so-called "summary remembrance" is a kind of amnesia in which 
there are defects here and there in the memory-store clustered about 
some critical period, some of the experiences being intact and others 
destroyed. When the amnesia extends not only over some critical period 
(such as the time of an accident, fit, trauma, fright, etc.), but backward far 
beyond the period in question, for days, months, or years, it is called retro- 
grade or retroactive amnesia. 

Disorders of Attention. — Condillac stated that if amid a multi- 
tude of sensations there is one which predominates by its intensity, it 
is thereby transformed into attention. Ribot 1 regards spontaneous 
attention as always caused by emotional states. The writer believes, 
with Ziehen, that attention is never voluntary, but always spontaneous ; 
that it is the awakening of one idea from the impressions of the in- 
numerable sensations impinging on our sensory surfaces. Such atten- 
tion depends upon several factors. One is intensity. Another is cor- 
respondence of the received sensation with some latent memory-picture. 
A third factor is the affective quality or sensory tone of the sensation. 
A fourth factor is the combination of latent ideas. 

The disorders of attention are morbid diminution and morbid in- 
crease. The former is extreme in idiots, and noteworthy in patients 
dominated by strong hallucinations or overpowering delusions. By 
pathological increase of attention is meant the crowding of numerous 
sensations and ideas into consciousness, such as is observed, for instance, 
in maniacal states. 

Accelerated Flow of Ideas. — In the highest degree of pathological 
increase in the stream of thought we observe not only a rapid concate- 
nation of the associated ideas, but their swift transfer to the cortical 
motor areas, so that gesticulation, logorrhea, and motor agitation become 
strikingly prominent. It is an ideomotor excitement. It may be so 
severe as to present a secondary incoherence. In moderate degrees of 
acceleration the words spoken by the patient may, by their sound, arouse 
associations, so that we observe in the speech of the patient a tendency 
to rhyming assonances and verbigeration. The almost constant com- 
bination of augmented flow of thought with an exalted and cheerful 
mood is interesting and, at the same time, difficult to explain. Some 
believe that the exaltation is due to the patient's feeling of great facility 

1 "The Psychology of Attention." 



GENERAL SYMPTOMATOLOGY OF INSANITY. 743 

and fecundity of thought. Others, again, consider the exaltation as the 
primary phenomenon, and that, as in normal individuals, the exal- 
tation induces the free play of ideas. But it is probable that the cheer- 
ful mood and accelerated flight of ideas are simultaneous manifestations 
of the morbid process. 

Diminished Flow of Ideas. — In this symptom we have features 
quite opposite to those manifested in ideomotor excitement. In the 
place of increased we have diminished attention to the sensory stimulus, 
and retarded transfer of the awakened idea-associations to the motor 
areas (motor inhibition). In any noteworthy inhibition of the flow of 
thought we observe also difficult and retarded recollection and more or 
less complete cessation of all voluntary movement. Speech becomes 
slow, the patient seeking laboriously for words, and these are simply 
whispered, not spoken aloud. In severe degrees only slight move- 
ments of the lips are made, or complete mutism is presented. Some- 
times a word or phrase will be repeated monotonously over and over ; a 
single motion of the arm or body may be reiterated for hours (stereotyped 
movements). The general musculature of the body may be completely 
relaxed and flaccid (motor-inhibition with resolution) or in a state of 
tension (catatonic inhibition), or in the condition known as flexibilitas 
cerea. The condition designated as stupor comprises three cardinal 
symptoms — viz., diminished attention, thought-inhibition, and motor- 
inhibition. Stupor may be primary or secondary. When secondary, it 
is ordinarily induced by hallucinations of ecstatic, dreadful, or impera- 
tive nature. Stupor from ecstatic hallucinations is frequent in hysteria 
and epilepsy, and from dreadful hallucinations in melancholia (catatonic 
syndrome). Primary stupor is another name for primary dementia. 

Depression with thought-inhibition is common, and among the de- 
pressed affects associated with it we observe most frequently anxiety. 
According to the motor symptoms prominent in such cases, such as 
flaccidity (or resolution), catatonic rigidity, and restlessness, we dis- 
tinguish three types — viz., melancholia passiva, melancholia attonita, 
and melancholia agitata. The usual motor inhibition is concealed in 
melancholia agitata by the expression movements of anguish, such as 
wringing the hands ; picking the fingers, face, or scalp ; restless moving 
to and fro, anteroposterior or lateral oscillations of the bodv, and the 
like. 

In the diagnosis of thought-inhibition Ave must be careful to distin- 
guish, in the first place, actual defects of intelligence or conditions of 
dementia. Then we must distinguish the primary form without affects 
and with affects, and the form secondary to hallucinations and delusions. 
Some of the diagnostic criteria are : 

Dementia and idiocy are stationary or progressive conditions, while, 
on the other hand, in thought-inhibition there are transitory variations — 
intervals of diminished inhibition. 

Thought-inhibition is almost always combined with motor-inhibition, 
while this latter symptom is not observed in defects of intelligence. 

The judgment-associations in defective intelligence are also defective, 
and wrong answers are often given to questions. This is not true of 



744 MENTAL DISEASES. 

states of thought-inhibition, where correct answers are generally made, 
if made at all. 

Incoherence. — Incoherence is a dissociation of serially related 
ideas. Such dissociation may involve also the sensations which arouse 
a series of ideas and the motor sequence of a series of ideas. In a 
complete general incoherence, then, the patient recognizes neither per- 
sons nor objects, calls everything by its wrong name (pseudoparaphasia), 
uses everything wrongly (pseudo-apraxia), answers questions with abso- 
lute irrelevancy, and shows even incoordination and pseudo-ataxia in 
his movements. When the incoherence is marked in the sensory percep- 
tions, we speak of lack of orientation ; it was formerly termed a disorder 
of self-consciousness. When the motor incoordination is extreme, it 
may amount to veritable jactitation and pseudochorea. Incoherence is 
most remarkable, however, in the speech, writing, and mimetic expres- 
sion of the patient. The gestures and facial movements have no rela- 
tion to the contents of consciousness ; laughter may accompany dreadful 
hallucinations and a tearful countenance some jocose idea. As regards 
speech, if the incoherence is of mild degree, only the sentences are 
misplaced ; if of severe degree, the very words in the sentence are 
jumbled together, and we observe the phenomenon of verbigeration 
and the manufacture of new words. The handwriting of the patient 
may present the same incoherence as the speech. The term confusional 
insanity has been used to describe the form in which the symptoms are 
want of orientation, incoherence of ideas, and motor incoherence. In- 
coherence may be primary or secondary, generally the latter. As a 
primary phenomenon, it is the cardinal symptom of the incoherent form 
of paranoia. Secondary incoherence is due to extreme rapidity of the 
stream of ideas, to accumulation of rapidly changing delusions and hal- 
lucinations, to strong depressing affects, and finally to actual defect of 
intelligence. It is often difficult to distinguish primary from secondary 
incoherence, and far from easy to differentiate the causes of the latter. 

Delusions and Imperative Ideas. — Ideas are associated with judg- 
ments as to similarity, simultaneity, properties of objects, etc., and such 
judgment may be correct or erroneous in normal individuals, according 
to the weakness or strength of judgment, and according to the degree 
of correspondence between the sensory perceptions and the objects or 
events of the external world. The normal mind, however, generally 
corrects its errors of judgment by repeated experience and better edu- 
cation — a physiological process. The pathological errors of judgment 
are the delusions of the insane. These delusions are usually judgments 
founded upon incorrect sensory impressions, such as illusions and hallu- 
cinations. They are rarely corrected by experience, as is the case with 
physiological error. But there are many cases in which a definite 
boundary-line can not be drawn between the delusions of the sane and 
those of the insane, as, for instance, in the delusions of the superstitious 
and of spiritualists. 

The delusion is the most frequent form of pathological error of 
judgment, but the imperative idea is also a pathological error of judg- 
ment, though less commonly met with. Delusions are seldom influenced 
by, or, in fact, associated with, attempts at correction by the judgment ; 



GENERAL SYMPTOMATOLOGY OF INSANITY. 745 

whereas imperative ideas are usually recognized as morbid by the patient, 
but force themselves into consciousness despite the efforts of the judg- 
ment to dislodge them. 

A delusion may arise in the mind as a primary idea without an 
incorrect sensory basis, in the same way as an imperative idea. It may 
be a logical deduction from other delusions, or, as already stated, be the 
product of illusions or hallucinations. It may be the result of a dream 
carried over by weakened judgment into the waking life. It may 
develop, as in melancholia or mania, from the attempts of a patient to 
explain the origin of his depression or exaltation. Thus, the melan- 
choliac believes that his suffering must be due to his bad conscience, to 
some sin that he has committed, to some serious disease of his viscera, 
and the like. The patient with exaltation of his emotional life develops 
expansive ideas as to his strength, beauty, intellect, wealth, position, and 
so on. The character of delusions developed in the insane is as multi- 
form as are the ideas in the mind of man. 

Depressive delusions are almost always connected with the idea of 
having committed a sin, of having some disease (hypochondriasis), of 
having lost all property, or of persecution. Contrasted or antagonistic 
delusions of grandeur are sometimes observed at the same time in con- 
nection with depressive delusions. Thus, one patient, while weeping and 
wringing her hands, told me she was the queen of the world, but was 
unable to do her duty because she did not know all languages. Ziehen 
tells of a patient who said, " I was the Holy Ghost. Had I used my 
omnipotence, we would all be happy now. But I am cursed. I have 
killed the Holy Ghost. The whole world is in misery and dread 
through me." Hypochondriacal delusions generally arise from disorders 
of common or organic sensibility, cenesthetic sensory impressions, 
though they also develop from attempts at explanation of a depressed 
mood and from hallucinations. The patient is certain he has cancer, 
consumption, syphilis, brain-softening ; that he is impotent ; that his 
alimentary canal is closed up ; that his brain has been removed ; that his 
viscera and tissues have been metamorphosed into stone, glass, wood, 
and the like. A peculiar form of hypochondriacal delusion is the so- 
called micromania not infrequently observed in depressed periods of 
general paresis. Patients with micromania assert that whole viscera 
have been removed from their bodies, that their blood is all gone, and 
that they have been reduced in size. Thus, one patient told me she was 
so small she could be put into a pill-box. Another said his intestines 
were absolutely closed up and he should have to be cut open to have 
the obstacles removed. The delusion of pregnancy arises from perver- 
sion of abdominal sensory impressions. 

The delusion of persecution differs from the other depressive de- 
lusions in that it has to do with the enmity of other persons in the 
environment, whereas these are concerned altogether with the ego of the 
patient, his own conscience, his own mind, his own body. The delusion 
of persecution is important to the general practitioner, because it is very 
common, because it is met with so often outside of institutions, because 
it not infrequently leads to assaults and murder, and because its signifi- 
cance in prognosis varies with the species of mental disorder in which it 



746 MENTAL DISEASES. 

is encountered. It is observed, for instance, in toxic insanities which 
are curable; in melancholia, in which cure is difficult; and in paranoia, 
which is incurable. The most common origin of the delusion of perse- 
cution is from hallucinations. The patient hears mocking or threaten- 
ing voices, he tastes poisons in his food, he sees lowering looks and 
menacing gestures, he feels singular sensations in his body which must 
be due to irritant poisons thrown upon him or to electricity, or he smells 
noxious gases. The delusion of persecution may grow out of a series 
of hypochondriacal delusions, in the attempt of the patient to explain 
the origin of his miseries. It may arise also from the delusion of 
having committed a sin or crime, the patient imagining that every one 
hates him and follows him to punish him. Sometimes these persecutory 
delusions are referred to the influence of unseen agencies — hypnotism, 
telepathy, electricity, magnetism. Sometimes they have to do with the 
property or social position of the patient ; he believes his belongings are 
being stolen, or his character maligned. Sometimes erotic ideas are 
bound up with persecutory ideas ; a woman believes herself secretly 
cohabited with at night, or even by day, through occult means ; a man 
thinks he is made impotent, that his seminal fluid is being drawn off. 
Obviously, these latter ideas often rest upon perverted sensory impres- 
sions received from the sexual organs. In seeking to discover the 
origin of the persecution, the patient often at first settles upon some one 
definite individual, but later, when he finds the methods of persecution 
innumerable and that his enemies follow him wherever he goes, he can 
not believe that any one person could do so much ; he reaches the con- 
clusion that it must be a wide-spread conspiracy, such as could be carried 
out only by some large affiliation of persons, such as societies of Free- 
masons, anarchists, Jesuits, lawyers, and police. The delusion of per- 
secution occasionally develops from a delusion of grandeur ; the patient 
believes he is persecuted because of his wealth or exalted position. 
More often, however, the contrary is the case, the patient coming to 
believe himself some extraordinary personage because of the persecu- 
tions to which he is subjected. 

Another interesting form of depressed delusion is that of negation 
(delire de negation generalise), which has its origin usually from an idea 
of having sinned. The patient thinks he must be the devil himself, his 
sin is so great ; consequently he can never die, he must suffer forever ; 
then, with the growing idea of the enormity of his sin, he comes to 
believe that God and mankind and the world exist no more. 

Delusions of grandeur vary from simple, expansive ideas of the 
patient's importance, prerogatives, and powers, to delusions of being 
inventors, geniuses, prophets, reformers, titled and royal personages, and 
even Christ, God, and the mother of God. Besides his own person- 
ality, his environment maybe vested with grandiose qualities — his room 
a palace, his straw hat a crown, pebbles diamonds, his children prin- 
cesses, and so on. A peculiarity of the ideas of grandeur observed in 
general paresis, which is quite pathognomonic, is their enormity or, 
rather, monstrosity. It is not enough to be wealthy, but sextillions of 
planets can not hold the gold and jewels. It is not sufficient to have a 
dozen children, but billions of children are given birth to nightly by his 



GENERAL SYMPTOMATOLOGY OF LNSANLTY. 747 

innumerable wives. He will make a new Niagara, by bringing the 
Pacific Ocean over the Andes. Should sexual ideas prevail, he may 
say that his penis is a mile long, and his testicles are huge diamonds. 
He will move the asylum across the United States on a road of solid 
gold. Such enormities betoken great weakening of the intellect and 
judgment. 

Primary delusions conduce more to fixity than delusions secondary 
to hallucinations. The latter, depending as they do upon the stability 
or instability of the morbid sensory impressions, change with these. 
When delusions become fixed, they tend to crystallize or become sys- 
tematized. Systematization consists of combining with the fixed idea 
complementary delusions in a more or less logical order or of the fan- 
tastic elaboration of the original delusion. The degree of organization 
and perfection of the delusional structure will depend upon fancy, 
logical faculty, social position, and education of the patient. The most 
common form of systematization is in the development of secondary 
grandiose ideas upon a persecutory basis. But almost any of the de- 
pressed and exalted delusions previously described may become fixed, 
systematized, and permanent through the life of the patient. 

Delusions may have a retroactive effect in awakening sensory im- 
pressions, instead of being aroused by them — that is, may induce illu- 
sions and hallucinations. For example, the persecuted patient perceives 
voices, odors, tastes, pains, etc., often because of his mind being in a 
state of expectant attention. 

Imperative ideas force themselves into consciousness in spite of 
the efforts of the patient — who recognizes their morbid character — to 
correct them. They are accompanied, almost without exception, by a 
depressive affect, a painful sensory tone. They are extremely common 
in neurasthenia. Senseless phrases or doggerel repeat themselves over 
and over in the patient's mind. The many varieties of phobia are 
familiar examples of imperative ideas in neurasthenics (agoraphobia, 
claustrophobia, mysophobia, etc.). Imperative ideas are also observed 
in melancholia and in a form of insanity which has been designated as 
insanity from imperative ideas. In very rare instances they are en- 
countered in early stages of general paresis. They always develop on 
the basis of a congenital or acquired neuropathic or psychopathic con- 
stitution, and are apt to become obstinate features in the mental organi- 
zation. Almost every imperative idea has its inception in some sort of 
sensory impression, and the idea may lead to compulsory actions on the 
part of the patient. But between the imperative idea and the conse- 
quent action there is generally a play of judgment, a faltering between 
the imperative idea and antagonistic or inhibiting concepts. For 
instance, the patient feels a compulsion to lock a door which he feels 
sure he has already locked. After an inward debate as to whether he 
should go back and assure himself that it is locked, which may last 
many minutes or longer, he goes to lock it, and on leaving the door 
again the imperative idea arises that it is not locked. The same play 
of antithetic ideas may occur in reference to anything — the addressing 
of a letter, the return of a book to a shelf, acts of dressing and un- 
dressing, the crossing of a street, etc. In some cases the imperative 



748 MENTAL DISEASES. 

idea takes the form of compulsion to jump from a height, to laugh in 
unseemly places; or obscene and sacrilegious words, sentences, and fan- 
cies may thrust themselves obstinately into the consciousness. For 
example, a gentleman, and a good Christian, came to me recently over- 
whelmed with the sacrilegious conceptions which first came to him at a 
church-service a week or two before — ideas of cohabitation with the 
Virgin Mary and filthy expressions in relation to Christ. A lady con- 
sulted me about a morbid fear that she had of canary birds. She 
could not enter a house or hotel in which there was a canary bird, 
because she was afraid that bird-seed might get about and in some way 
get into her mouth, be swallowed, and grow in her stomach. The con~ 
tents of these imperative concepts are as varied as those of delusions, 
though they are almost, without exception, trivial or unpleasant. 

Folie du doute is a form of mental disorder in which compulsory 
ideas assert themselves in the form of questions, religious, metaphysi- 
cal, or in regard to the most trivial things or events (Shall I do this or 
that ? Why is the table round ? Why is the chair by the bed ? Why 
are two and two four ?). One young lady is so incapable of deciding 
any question that conies up in her mind that she does not know 
whether she ought to dress or undress, go to bed, eat, sleep, pray, or 
consult a doctor. Every trivial question of the day requires hours 
of painful and agonizing debate in her mind. 

Imperative ideas frequently impel to compulsory speech and actions. 
Coprolalia is a not uncommon form of imperative speech in wdiich the 
patient is impelled to the utterance of obscene words. Quite analo- 
gously the patient may be made to make grimaces, or may develop the 
so-called maladie des tics. 

Weakness of Judgment. — Innumerable memory-pictures and 
associated ideas take part in the process of comparison and decision 
which we know as judgment. Hence any disorder of memory and of 
its associations, such as loss, defect, or perversions (delusions, hallucina- 
tions, or illusions), must naturally influence the character of the judg- 
ment. One of the common conditions which impairs judgment is, 
therefore, intellectual defect, such as congenital or acquired mental 
weakness. The criteria of idiocy and dementia are poverty of ideas 
and idea-associations and weakness of judgment. When delusions or 
imperative ideas exist, the errors of judgment are due to the overriding 
and eclipsing by single ideas and idea-associations of all others which 
would in the normal mind give balance, control, and revision to the 
judgment. Defective judgment varies in degree from a slight loss of 
the critical faculty to complete deficiency. When the judgment is 
markedly defective, it depends upon actual organic changes in the 
brain, such as we observe in idiocy, terminal dementia, senile dementia, 
and general paresis, and hence as a symptom it is far more ominous 
than delusions and imperative ideas, which usually rest upon a func- 
tional pathological basis. Its significance, then, demands a careful 
differentiation of this symptom from others with which it might be 
confused, such as incoherence and thought-inhibition. In incoherence 
the threads of thought are constantly lost. In thought-inhibition there 
are a depressive affect and extraordinary slowness of association with 



GENERAL SY3IPT03IAT0L0GY OF INSANITY. 749 

correspondingly tardy answers, and, besides, there are variations of depth 
of inhibition, so that at times complicated answers and judgments are 
readily given. In actual weakness of judgment the judgments rendered 
are false, and the more incorrect, the more complicated the questions. 

DISORDERS OF ACTIONS. 

The actions or conduct of a patient depend directly and necessarily 
upon pathological elements in some part of the psychological processes 
— sensation, memory-pictures, idea-associations, and their emotional 
affects. They may be classified, following Ziehen, as — 

1. Actions induced by sensory disorders. 

2. Actions induced by disorders of memory. 

3. Actions induced by disorders of the emotions. 

4. Actions induced by disorders of the idea-association. 

Actions Induced by Sensory Disorders. — Hallucinations and 
illusions affect the conduct of a patient often markedly, and their influ- 
ence is always greater than that of normal sensations. Their dominance 
is the greater in proportion to their number and to the rapidity of their 
accumulation. Hallucinations gathered slowly in the course of weeks 
or months, while they may not be corrected, are at least subject to a 
certain amount of control by the inhibition of normal ideas. In the 
most chronic forms of hallucination the voices, common sensations, and 
visions tend to be ignored and to influence to a very slight degree the 
conduct of the patient. A very important practical feature in regard to 
hallucinations and their effects upon conduct is their uncertainty. They 
are never to be reckoned with, and one can never know what sudden 
violence or destructiveness may result from new hallucinations rising in 
the patient's brain. 

Actions Induced by Defects of Memory. — These are observed in 
congenital or acquired weak-mindedness, where the conduct is directly 
ordered by sensory impressions, without that intervention of the play 
of motives which we observe in normal individuals. They are more 
like the actions of the lower animals, which may be complete enough in 
their way, but are not motived by complicated abstract conceptions, 
because these are wanting. 

Actions Induced by Disorders of the Emotions. — As already 
elsewhere intimated, simple depressed emotions are accompanied by a 
general motor inhibition, and simple exalted emotions by a general 
motor agitation. But when the depressed affect attains to the degree of 
anxious dread, we may have a restlessness, a desire for flight, which in 
itself amounts to a motor agitation. This anxious state often leads to 
suicidal attempts, and even to homicidal assaults, arson, and other forms 
of crime and violence. The whole nervous system seems to be in such 
a state of tension that only an explosion can give relief. 

In apathetic conditions action is reduced to its minimum. 

Where the higher affects, which are at the basis of ethical concepts, 
are absent or lost, as in congenital or acquired states of mental weak- 
ness, crimes against person and property are common. 

In conditions of anger and rage there is at first a brief period of 



750 MENTAL DISEASES. 

speechlessness and immobility, followed by an explosion of blind and 
violent motor excitement, in which the most dangerous assaults may be 
made. 

In conditions of changeability or lability of the emotions, we ob- 
serve analogous motor states — sudden changes from weeping and wailing 
to boisterous cheerfulness, and vice versa. 

A study of emotional expression is of particular diagnostic value in 
insanity, but the features of such expression and gesticulation are so 
well known that they need no detailed description here. Each mood, 
be it simple depression, anxious terror, excitation, anger, apathy, or 
emotional lability, has its own familiar motor habiliments. 

Actions Induced by Disorders of the Idea-association or Stream 
of Thought. — Under this heading are gathered the multiform modes 
of action caused by increase in the flow of ideas, retardation of the 
stream of thought, incoherence, delusions, imperative ideas, and weak- 
ness of judgment. 

In increased rapidity of the flow of ideas we note motor agitation 
or morbid impulse to movement, varying from simple talkativeness, 
with active play of expression, to loud garrulity, grimaces, gesticula- 
tion, b^sy walking about, running, dancing, and, in extreme degrees, to 
undressing, destructiveness of clothing, bedding, furniture, and blind 
throwing about of the body in every conceivable way. This so-called 
primary motor agitation should be distinguished from the motor agita- 
tion which is secondary to crowding hallucinations (hallucinatory agita- 
tion) and to emotions like terror and anger (affective agitation). 

The behavior of the movements in regard to retarded flow of thought 
has already been briefly alluded to. There is a general motor inhibition, 
varying from simple slowness and difficulty of executing any movement, 
whether of speech or other muscles, to a complete cessation of volun- 
tary movements, a stuporous or attonitous condition, in which the 
muscles may be absolutely at rest and flaccid or, on the other hand, 
in a condition of catatonic tension. In true catatonic tension every 
attempt at passive movement is resisted, but in another form of this 
there is a waxy flexibility of the muscles, so that the limbs yield readily 
to any passive motion, remaining in whatever position the physician 
desires to place them. Occasionally one encounters in cases of retarded 
idea-associations, as an expression of motor inhibition, a tendency to the 
repetition of some restricted voluntary movement in a rhythmical, 
stereotyped way for days, weeks, months at a time. Such stereotyped 
motions may be simple anteroposterior oscillations, lateral oscillations, 
whirling, walking to and fro or in a circle, waving the hands rhythmi- 
cally — forms of tics exceedingly common in idiocy and imbecility, 
but common enough in melancholias and terminal dementias. The 
repetition of stereotyped or automatic phrases is analogous in character 
to such morbid movements. Motor inhibition is primary or secondary. 
The primary form is generally a simple resolution or flaccidity, occa- 
sionally a slight catatonic tension or flexibilitas cerea. Secondary motor 
inhibition is due to hallucinations, delusions, aud states of mental weak- 
ness. 



GENERAL SYMPTOMATOLOGY OF INSANITY. 



751 



Incoherence of ideas leads to a dissociation also in the motor ex- 
pressions of ideas, parapraxia, paramimia, incoordination, pseudo-ataxia, 
incoherent agitation, chorea magna, and jactitation. Such motor agita- 
tion may be primary or may be the secondary result of innumerable 
clashing hallucinations and delusions, rapidity of the flight of ideas or 
of intellectual defects. 

Grandiose delusions exert their own peculiar influence on the 
demeanor and speech of the patient, according to the contents of the 
exalted ideas. We observe the proud bearing ; the self-sufficient, 
haughty, or secret smile ; the withdrawing from others ; the tendency to 
decoration of the person ; the attempts to act the parts of the personage 
he imagines himself to be ; the striking peculiarities of handwriting. 
In some instances delusions of grandeur lead to homicidal, rarely 
suicidal, attempts (self-crucifixion with the delusion of being Christ). 
Grandiose erotic ideas sometimes occasion masturbation. Coprophagy 
and other filthy habits may depend upon grandiose delusions as to 
extraordinary virtues of the patient's excretions. 

In depressed delusions, particularly as regards ideas of sin and 
poverty, we observe the characteristic melancholy facial expression 
and attitudes. Attempts at suicide are frequent, and sometimes 
self-mutilation. Abstention from food is especially common with 
the delusion of poverty, the patient feeling that he can not pay for 
anything. 

Hypochondriacal ideas influence markedly the patient's actions and 
conduct. The hypochondriac may neglect every duty in the constant 
contemplation of his symptoms. He reads medical books, goes from 
one physician to another, takes to his bed perhaps permanently, and so 
on. The .effects of hypochondriasis on motor functions are frequently 
remarkable, leading sometimes to astasia or abasia, or both ; to hypo- 
chondriacal ataxia, tremor, or convulsive movements of the extremities. 
These hypochondriacal motor conditions are always the result of a series 
of morbid judgments on a hypochondriacal basis, and are to be distin- 
guished from similar hysterical states which have an autochthonous origin 
without any antecedent conscious reasoning process. 

The persecutory delusions lead to systems of self-protection of the 
most varied kind. Barricades, stopping up of cracks and keyholes, 
the wearing of peculiar clothing (silk, paper, etc., for instance, as a 
guard against electrical shocks), avoiding of food and drink which are 
suspected of containing poison, arming with weapons, frequent change 
of servants or residence, and complaints to the police or judicial 
authorities. Homicide is common in these cases. 

Imperative ideas lead to imperative movements and actions, and 
generally in spite of the well-preserved consciousness and judgment of 
the patient. Such imperative actions are as various in character as the 
imperative ideas to which they correspond. 1 

Accompanying Physical Disorders in Insanity. — Among the 

1 The foregoing account of the psycho pathology of insanity is largely a presenta- 
tion of the views of Ziehen, to whose excellent work the author must refer readers for 
greater detail. 



752 



MENTAL DISEASES. 



many somatic symptoms which may complicate or accompany psychoses 
are chiefly to be mentioned the following : 

1. Motor disorders. 

2. Sensory disorders. 

3. Reflex disorders. 

4. Trophic disorders. 

5. Secretory and excretory disorders. 

6. Temperature disorders. 

7. Vascular disorders. 

Motor Disorders. — These may be manifested in the form of morbid 
movements or paralysis. In the first category are assembled such 
symptoms as epilepsy, convulsions, chorea, choreiform movements, 
tremor, tics, ataxia, masticatory spasm, and the like. The following 
table, modified from Ziehen, gives a general summary of the paralytic 
symptoms noted in insanity : 



Form of 
Paralysis. 


Character. 


Trophic 

Disturbances. 


Spasticity 

or 
Flaccidity. 


Sensory 
Disorders. 


Deep 
Reflexes. 


Hypochon- 
driacal. 


Usually limited 
to a certain 
form of move- 
ment. 


No atrophy. 


Flaccidity. 


None. 


Normal. 


Hysterical. 


Monop legia, 
hemiplegia, or 
paraplegia. 


Disuse atro- 
phy. 


Frequently 
contractures. 


Hemianes- 
thesias, etc. 


Normal or 
hypertypical. 


Cortical. 


Monoplegia or 
hemiplegia. 


Disuse atro- 
phy- 


Eigidity. con- 
tractures, lo- 
cal spasms. 


Paresthesias, 
occasionally 
anesthesias. 


Exaggerated 
usually. 


Pyramidal 
tract. 


Hemiplegia or 
paraplegia. 


Disuse atro- 
phy. 


Spasticity, 
contractures 
frequently. 


Occasionally 
anesthesia, 
hemianop- 
sia, etc. 


Exaggerated. 


Peripheral. 


Multiple or sin- 
gle. 


True atrophy 
with degen- 
erative re- 
action. 


Flaccidity. 


Hyperesthes- 
ias, stocking 
and glove 
areas of an- 
esthesias 
often. 


Lost. 



Sensory Disorders. — Anesthesias and hyperesthesias have already 
been mentioned, but hyperalgesias and paresthesias of divers kinds are 
encountered among the psychoses, such as headache, migraine, neural- 
gias, feeling of fullness in the head, scotomata, tinnitus aurium, and so 
on. Neuralgia is occasionally a cause of insanity. Migraine is a fre- 
quent precursor of general paresis and concomitant of epilepsy. Light- 
ning pains are noted in tabic types of dementia paralytica. Neurasthenic 
pains and paresthesias in the extremities, spine, and head are found in 



GENERAL SYMPTOMATOLOGY OF INSANITY. 753 

neurasthenic forms of insanity. Where hysteria complicates a psychosis, 
there are often observed the sensory disturbances characteristic of that 
malady. 

Reflex Disorders. — Changes in the reflexes are important in but a 
few forms of insanity. In paralytic dementia we observe nearly always 
exaggerated tendon-reflexes, but in tabic types thev are lost. They are 
lost also in psychoses complicated with multiple neuritis, and frequently 
in cases with diabetes, and in morphinomania. The deep reflexes are 
exaggerated in senile dementia, many acute affective insanities, hysteria, 
epilepsy, and in patients with accompanying multiple sclerosis. The 
state of the superficial reflexes possesses little significance, except in in- 
sanity associated with hysteria and organic disorders of the brain, spinal 
cord, or peripheral nerves. 

The Argyll-Robertson pupil is met with almost constantly in gen- 
eral paresis. The pupils in all cases of insanity should be examined as 
to their equality, size, and reaction to light, and in accommodation. 
Loss of reaction to light may be observed, besides, in general paresis, in 
syphilitic insanities, senile insanity, and in some alcoholic cases ; it 
means organic disease of the brain. In rare instances a transitory 
rigidity of the pupil occurs in epilepsy and morphinomania. Inequality 
of pupils is very common in organic and occasional in functional in- 
sanities. 

Trophic Disorders. — General disturbances of nutrition, variations 
in bodily weight, are commonly noted, and possess considerable signifi- 
cance. Thus, rapid increase in weight is characteristic of the progress of 
an acute psychosis to terminal dementia ; if, however, it accompanies an 
improvement in mental symptoms, it betokens convalescence. In some 
cases enormous decrease in weight, in association with pernicious anemia, 
leads to a fatal termination. Certain forms of insanity, especially 
organic, notably paralytic dementia, present a remarkable trophic 
disturbance in the bones, a fragilitas ossiuni, inducing easy fracture. 
Decubitus is observed in bedridden insane patients, particularly paretics. 

Hematoma auris, othematoma, or the u insane ear." is a deformity 
of the ear produced by a hemorrhage into the substance of the auricle, 
usually between the perichondrium and the cartilage. It is undoubtedly 
traumatic in its origin, but there is fundamentally some change in the 
vascular walls in certain cases of chronic insanity, rendering them 
fragile and easily ruptured by the most trivial pressure or injury. 
Such effusions of blood do occur in normal individuals (athletes and 
boxers), but always from severe trauma. The frequency of hematoma 
auris in general paralysis, and in many chronic forms of insanity is 
only explicable on the hypothesis of some trophic change in the vessel- 
walls. 

Secretory Disorders. — The secretion of tears is generally reduced 
or absent in melancholia. 

The saliva may be diminished in quantity in melancholia. More 
often in many forms of insanity it is increased, the excessive secretion 
amounting sometimes to a sialorrhea. The increase is due to constant 
mastication, to illusions and hallucinations of taste, and sometimes to 

43 



754 MENTAL DISEASES. 

irritative stimuli in the secretory centers. Drooling may give the ap- 
pearance of an increase of salivary flow, because of relaxation of the 
oral and buccal muscles, or because the secretion is not swallowed. 

Diminution or increase of hydrochloric acid in the gastric juice is 
noted in many cases of insanity, and the quantity may be determined 
by the Sjoqvist method. Hypochlorhydria exists in common in states 
of congenital and acquired intellectual defect and in general paresis. 
Hyperchlorhydria is not infrequently met with in cardialgic attacks, 
after epileptic seizures, and in catatonic conditions. 

As regards the urine, quantitative and qualitative changes are very 
common in insanity. These changes may be the expression of abnormal 
metabolism in the central nervous system, of abnormal metabolism in 
other parts of the body induced by disease of the central nervous sys- 
tem, or of vasomotor changes in the kidneys brought about by the 
psychoneurosis. Polyuria is observed in many organic psychoses and 
in hysterical complications. Oliguria is characteristic of melancholy 
and stuporous conditions. In hysterical insanity there is frequently an 
alternation between oliguria and polyuria. 

As regards the qualitative changes in the urine of the insane, we 
are year by year recognizing more and more the importance of investi- 
gation in this direction. There is no doubt that the deeper our re- 
searches go into the chemistry of metabolism and catabolism, the 
nearer do we attain to a better understanding of the mysterious nutri- 
tional processes that have to do with the construction of the blood and 
that underlie so many psychoses. Albumin, peptone, and propeptone 
are found not infrequently in the urine of cases of organic insanity, in 
delirium tremens, in epilepsy, and in acute mania. Their presence is 
often transitory, and unaccompanied by renal disease. Hyalin cylinders 
are also often observed in severely excited conditions. 

Excessive phosphaturia is noteworthy in many cases of great cere- 
bral excitement, and after epileptiform and apoplectiform seizures. In 
chronic brain disorders the quantity of phosphoric acid is diminished 
below the normal. 

The chlorids are lessened in quantity in melancholia. They are 
increased in the early stages of paresis, but diminish with the progress 
of the disease to dementia. 

Sulphates and the aromatic ethereal sulphates (the latter being the 
product of destructive proteid metabolism) are increased in febrile con- 
ditions, and in conditions attended with much tissue-Avaste. 

Urea is also representative of destructive proteid metabolism, and is 
an index of the general nitrogenous metabolism of the body. It is 
increased in conditions associated with tissue-waste, diminished in states 
of malnutrition. Uric acid and the urates have much the same rela- 
tion. 

Oxaluria (any increase above the normal amount excreted in twenty- 
four hours — viz., -^ of a grain) is observed in certain nervous and 
mental disorders, but its precise significance still requires determination. 

Urobilinuria and bilirubinuria have occasionally been noted in gen- 
eral paresis. 



GENERAL SYMPTOMATOLOGY OF INSANITY. 755 

Glycosuria, with or without polyuria, has often been observed in 
various organic psychoses. It may be intermittent, transitory, or per- 
manent. 

Acetonuria is encountered in general paresis and epilepsy at times, as 
also in psychoses attended with malnutrition, as, for instance, melancholia. 

Indican should be sought for, as it is an indication of albuminous 
putrefaction. It is significant of auto-intoxication. 

There is a wide region open to the pathological chemist for discov- 
eries in the feces, as well as the urine, of relations between metabolism 
and psycopathic disorders. 

Menstruation is often disordered in insanity. Amenorrhea is the 
rule in acute psychoses of any form, due undoubtedly to profound 
changes in the general nervous system influencing the spinal centers for 
ovulation and menstruation. The cessation of menstruation with the 
onset of an acute psychosis is often mistakenly supposed by the laity to 
show some etiological relation between the genital organs and the in- 
sanity. The return of the menses is one of the early signs of con- 
valescence from acute mania and acute melancholia. Naturally, it 
would not be correct to ascribe amenorrhea in all cases to simply ner- 
vous inhibition, because it may arise in all kinds of psychoses as the 
result of actual genital disease or of marked anemia. 

Temperature-changes in Insanity. — The physiological oscillations 
of temperature are greater and more irregular in the insane than in 
normal individuals. In general, however, insanity may be said to run 
a n on -febrile course. 

Subnormal temperatures are frequently observed in melancholia, 
stuporous states, general paresis, idiocy, and occasionally in conditions 
of great excitement. In these last they are apt to indicate approaching 
collapse. 

Hypernormal temperatures are found in many psychoses, sometimes 
from very slight peripheral irritations, such as retention of urine, 
gastric catarrh, constipation, mild bronchitis, decubitus, sometimes from 
organic changes in thermogenic centers. Hysterical complications may 
be associated with hysterical fever. Motor agitation in mania, acute 
paranoia, melancholia, and so on, may, if marked, give rise to febrile 
symptoms. The status epilepticus and convulsive seizures of general 
paresis increase the temperature, as a rule, to a noteworthy degree. 
Many Avriters have described diurnal oscillations of temperature, varia- 
tions from day to day, asymmetrical axillary temperature, and general 
subnormal and hypernormal conditions of temperature in paralytic 
dementia ; and some years ago, in association with Dr. Langdou, I 
undertook a verification of these statements at the Hudson River State 
Hospital for the Insane. 1 These are the conclusions we drew from a 
study of the temperature in twenty-five cases of general paresis : 

1. As regards the average bodily temperature, we find it to corre- 
spond to physiological norms. The statements of our predecessors as 
to hyperpyrexic or subnormal averages can not be sustained. 

1 " A Study of the Temperature in Twenty-five Cases of General Paralysis of the 
Insane," "Journal of Nervous and Mental Diseases," Nov., 1893. 



756 MENTAL DISEASES. 

2. The diurnal oscillations of temperature in paretics also corre- 
spond to physiological norms. The statements to be found in literature 
as to extraordinary daily variations being frequent in these cases are 
absolutely erroneous. 

3. Asymmetrical axillary differences are so small that they can not 
be considered as abnormal, and certainly not of any diagnostic sig- 
nificance. 

4. When unusual variations of temperature occur in general paretics, 
their cause must be sought for in conditions not related to the patho- 
logical phenomena of paralytic dementia, but depending upon thermo- 
genic features unrecognized by the physician, or " masked" by the 
mental state of the patient. Thus, in case two of our series, an in- 
creasing hyperpyrexia was noted during the second week's observations, 
but the pneumonia causing it was " masked " until the fifth or sixth 
day, the patient dying on the sixth day. Again, in case ten, where the 
highest single daily oscillation was 3.4 degrees, and the average daily 
oscillation for the week 2.2 degrees, the patient suffered from bed-sores, 
which undoubtedly produced some septicemia. That variations of tem- 
perature take place in connection with the paralytic and convulsive 
seizures of these cases we do not gainsay. 

Vascular Disorders. — The action of the heart and vessels is often 
influenced by insanity. The pulse is subject to acceleration in excited 
and neurasthenic states, and to retardation in stuporous conditions. 
Variations in arterial tension are particularly noticeable at times ; 
arterial spasm in any psychosis, but especially in melancholia, de- 
pressed types of general paresis, and in paranoia ; arterial paralysis as 
a sequel to this. No doubt strong mental shocks and depressive or 
exalting affects are associated with anomalies of the vasomotor innerva- 
tion. Perhaps many psychoses depend upon cerebral angioneuroses. 
The apoplectiform, epileptiform, and maniacal seizures of general 
paresis are believed to have their origin in these. Precordial anxiety, 
the neuropathic cervical globus, and other paresthetic and paralgesic 
sensations in the domain of the vagus, are also, in all likelihood, due 
to angioneurotic conditions. 



CHAPTER IV. 

METHODS OF EXAMINATION. 

The examination of a patient with mental disorder is a much more 
complex process than that of a case of physical disease, for it is necessary 
in the former not only to ascertain the present physical condition, as 
with ordinary patients, but also to investigate the mental state, which 
involves the employment of unusual and new methods, and brings us 
into contact with a novel series of psychic phenomena ; and, moreover, 
to attain our end, we need to study the whole past life of the patient, 
his diseases, accidents, schooling, occupation, environment, temperament, 



METHODS OF EXAMINATION. 757 

and character. Kor can we stop here, for it is of the greatest importance 
to inform ourselves as to conditions among his antecedents, to determine 
the type of family from which he sprang, and the presence or absence 
of an hereditary taint. There is, therefore, much to learn even before 
seeing the patient in person. The history of a case of insanity, as now 
recorded in our best insane hospitals, makes a rather formidable volume. 
It includes every kind of physical record made in general hospitals, as 
well as a thorough survey of the patient's life and ancestral conditions, 
and keen psychological analyses of his psychosis and its beginning and 
progress. 

In medicolegal cases we have to guard against several sources of 
error in our diagnosis, among which are the concealment of delusions by 
an actually insane patient and the simulation of insanity by a sane 
criminal. The forms of insanity usually simulated, because of the 
facility of so doing, are a maniacal state, dementia or stuporous melan- 
cholia, and epilepsy with insanity. Recently a notorious individual in 
Xew York simulated a paranoid condition with considerable success. 
Only one with excellent knowledge of the symptoms of insanity can 
simulate any form of psychic disorder so well as to defy the skill of the 
physician familiar with mental diseases. 

In general practice it sometimes occurs that peculiar forms of delirium, 
incident to severe visceral disease, may be at first mistaken for insanity. 
Thus I have, on a number of occasions, been called upon to assist in the 
commitment of patients to asylums, where careful examination showed 
the existence of either a transitory delirium in association with an apo- 
plectiform or other organic lesion of the brain, or a delirium from some 
such visceral condition as Bright's disease. Delirium of this kind is distin- 
guished, first, by the discovery of the associated and causative organic 
disease, and, secondly, by the usual non-conformity of the delirium to 
any special type of psychosis. 

Were I to formulate a series of rules to guide the examiner in his 
investigation of the mental condition of a patient, they would be some- 
what as follows ; yet it is to be remembered that these are not fixed 
rules, but subject to much modification by the tact, good judgment, and 
common sense of the examiner : 

1. It is to be presumed that previous to seeing the patient the ex- 
aminer has fully informed himself of all the facts to be furnished by 
relatives or friends, and has, when possible, inspected letters and other 
writings, which so often prove fruitful sources of information. 

2. Go to the patient as a physician, and not under the pretense of 
being something else — a device so often suggested by the family and 
friends. 

3. Proceed to the physical examination of the patient, during which 
tactful questioning will determine the direction to follow in further in- 
quiries. 

4. Gain the good will of the patient by kindness and consideration. 

5. Even if the patient is distrustful and uncommunicative, be 
politely persistent, and prolong the first examination, even to the extent 
of trving the patient, until the object is attained ; for many patients 



758 MENTAL DISEASES. 

will, when fatigued, finally yield to the friendly insistence of the 
examiner. 

6. If one examination is insufficient, however, have as many inter- 
views as are requisite for the purpose in view — a careful scientific 
diagnosis. In medicolegal investigations this is especially necessary. 

The method of study and investigation then resolves itself into the 
following : 

1. History of the family and of the patient. 

2. Observation of the patient. 

3. Examination of the patient's physical and mental condition. 
Family History and History of the Patient. — In the study of the 

heredity it is often worth while to construct a family tree, showing the 
relationship and hereditary diseases in the parents, grandparents, col- 
laterals, etc., and it is well to go carefully in every direction among the 
antecedents, and not be content with too concise a record of this im- 
portant factor. A special point should be made to determine in each 
case of mental or nervous disorder discovered whether the disorder present 
was acquired in the particular individual or in itself probably hereditary. 
Thus, epilepsy in an antecedent might be acquired (traumatic) and have 
much less bearing on the descendant than if it were the idiopathic type. 
Again, general paresis, senile dementia, a toxic psychosis, traumatic in- 
sanity, and so on, acquired disorders, as a rule, would have less signifi- 
cance than manic, melancholic, or circular psychoses, as determining 
factors in the individual case. It should be ascertained whether the 
parents were blood relations, and whether there was any great difference 
in their ages. Then the following questions should be answered, not 
only for each parent, but for the other blood relations, so far as it is 
possible : 

1. Character and temperament. 

2. Any special gifts, one-sided talents or peculiar traits, or criminal 
tendencies ? 

3. Any insanity ? If so, what type ? 

4. Any nervous diseases, such as epilepsy, tics, constitutional neu- 
rasthenia, chronic headaches, migraine, or hysteria ? 

5. Any constitutional disease (syphilis, tuberculosis, rheumatism, 
gout, diabetes) ? 

6. Any alcoholism or drug addiction ? Kind, extent, duration ? 

7. Any congenital infirmity or defect, such as blindness, deafness, 
dumbness, or deformities ? 

8. Were there brothers or sisters who died young; if so, of what? 
Then a series of questions is given to ascertain the personal history 

of the patient up until the time of onset of the psychosis : 

1. Are there brothers and sisters? If some died young, of what 
diseases ? Any special features in regard to them ? 

2. Any abnormality in the pregnancy or parturition of mother ? 

3. Convulsions or other nervous disorders in infancy or childhood ? 
Date and duration. 

4. Rachitis or febrile diseases in childhood? 

5 At what age did patient walk, speak, and complete dentition ? 



METHODS OF EXAMINATION. 759 

6. Character and temperament in childhood — any precocity, one- 
sided talent or stupidity ? 

7. Kind and degree of schooling ? 

8. Period of puberty — was its development normal? Any mastur- 
bation or perversion ? 

9. What is his occupation, and how has he carried it on? 

10. Character, temperament, religion, physical condition, diseases 
during adolescence. 

11. Any intemperance in the use of alcohol or drugs? Overwork? 
Shock ? Trauma to head ? Syphilis ? 

12. Any evidence of psychopathic constitution? 

13. Is the patient married? If any children, are they healthy? 

14. Any previous attacks of insanity? 

Having obtained the data relating to the family history and the per- 
sonal story of the patient's life up to the onset of the psychosis, we 
ask the following questions in relation to the history of the attack 
itself : 

1. Was the onset of the psychosis gradual or sudden? 

2. Were there any peculiarities noticed in the patient's conversation 
or behavior, or in his physical appearance, before the insanity became 
apparent ? 

3. Did he sleep well or badly? 

4. Had he lost weight? Did he eat well or little? 

5. Has he been excited or depressed or changeable ? 

6. Has he talked much, little, or not at all? 

7. Has he seemed to hear false voices or see imaginary things ? 

8. Has he seeemed to have delusions of suspicion, persecution, or 
of grandeur? 

9. Has he threatened or attempted suicide, or violence to others? 

10. Any offenses against morals or the law? 

11. Any evidence of disorder of memory or defect of intelligence? 
Observation of the Patient. — Very often the manner of reception 

of the physician by the patient, his facial expression, and bodily atti- 
tude afford strong clues to the type of mental disorder presented. There 
is a vast deal to learn by mere observation without making either a 
physical or mental examination. If it is possible to carry on such 
observation for a time without the patient's knowledge, it will be an 
advantage. 

The physiognomy, attitude, and behavior will first strike the examiner. 
He should note where the patient is, whether in bed or up and dressed, 
and if properly dressed. A simple melancholic state is quickly recog- 
nized by the facial expression of depression, silence, and by the hanging 
head, motionless body, or nervous picking at the hair, finger-nails, or 
clothing. In agitated melancholia there is an expression of anguish 
and motor activity in the way of restless walking to and fro, wringing 
the hands, tearing the hair, beating the breast, and so on. The manic 
patient is extraordinarily lively and cheerful in expression and exuberant 
in speech, gesture, and motion, leaping, running, dancing, singing, and 
talking incessantly. 



760 MENTAL DISEASES. 

The paranoid expression and manner are threatening, secretive, sus- 
picious, unfriendly, or ironical when the delusions are of a persecutory 
nature ; when grandiose ideas are present, a proud look and majestic 
bearing; are characteristic. 

In demented conditions, whether late stages of dementia precox, 
paresis, or other forms, the face is vacant and imbecile, the attitude 
completely apathetic, and the gait slipshod and halting. 

It is easy to recognize the ecstatic expression of epileptics in con- 
ditions of ecstasy, when they lie or stand perfectly still, lost in the con- 
templation of their visions. Paresis is often recognized at first sight 
by the unequal innervation of the two sides of the face, the muddy 
complexion, the overaction of the occipito-frontalis, the unequal pupils, 
and the frequently coarse tremor of the face when they try to speak. 

The catatonic type of dementia precox presents a mask-like, ex- 
pressionless face, and a completely apathetic pose or rigidity of the 
body. 

The chronic alcoholic is often quickly recognized by his swimming 
reddened eyes, cutis potatoria, and expression of roguish humor. 

This first view, too, differentiates speedily the idiot and imbecile from 
other types of mental disorder, and various stigmata of degeneration are 
frequently at once apparent, serving, by shape of head, character of ears, 
curious physiognomy, to distinguish the severe types of psychopathic 
constitution from others. 

Negligence in dress, or a tendency to overdress and overdecorate, 
when contrary to the normal habits of the individual, are indicative of 
a change in the mental state. 

If the patient is found in a stupor, we may have one of several 
conditions present, such as stupor with melancholia, hallucinatory stupor 
of paranoia, catatonic stupor, epileptic stupor, manic stupor, and occa- 
sionally stupor in cases of paresis ; and the expression of face is often a 
guide here to a diagnosis of the type of mental disease. 

An acute excitement or delirious condition may be due to various 
states, and one must exclude febrile diseases, alcohol and drug states, 
and organic diseases of the brain before making a diagnosis of the real 
psychoses, in which mental and motor excitement occur (such as paresis, 
epilepsy, manic-depressive states, and catatonia). 

Stereotypy of attitude, of movement, or of speech may be one of the 
first symptoms noted in our observation of the patient, and renders the 
diagnosis of the catatonic form of dementia prsecox easy. Stereotypy 
of attitude is a fixed, rigid position, with eyes closed, and every sense 
unreachable by any stimulus. Stereotypy of movement is the constant 
repetition of the selfsame movement of arms, legs, or face, usually sin- 
gular or droll in character. Stereotypy of speech is the reiteration over 
and over and over again of words or phrases, often in a peculiar sing- 
song tone. Stereotypy is occasionally found in other psychoses, but is 
most common in catatonia. 

Mannerisms in speech, dress, actions, peculiar grotesque and clown- 
ish or theatrical behavior are also characteristic of the catatonic syn- 
drome. To these we may add the phenomena of negativism and catalepsy 



METHODS OF EXAMINATION. 761 

to complete the picture of this form of dementia prsecox. Negativism 
is resistance to everything — to dressing, undressing, feeding, to answering 
questions (mutism), to passive movements, and the like. The catalepsy 
may be of the kind produced by automatic obedience or suggestibility. 
Place the patient in any conceivable attitude, he remains there (waxy 
flexibility). Set one of his arms going up and down or describing a 
circle, and he may continue to do this indefinitely (echopraxis), or he 
may repeat every word you say to him like an echo (echolalia). 

Having made these various observations of the patient, if he is 
talkative and more or less excited, we try to take down, steno- 
graphically, if possible, what he says, before asking him any questions 
or making our physical examination. From his speech we determine 
whether there is a flight of ideas, what the associations are, whether 
there are many sound associations, whether it is so rapid as to be " tele- 
graphic speech," whether he makes new words (neologisms), whether 
the speech is completely incoherent, the presence of reiterations, verbig- 
eration ; and often from the contents we determine the existence of 
delusions of a grandiose or persecutory nature and of hallucinations. 

From any writing of the patient shown to us before our interview 
we are frequently able to make a diagnosis. The peculiar elisions and 
reduplications of letters, syllables, words, and phrases of general paresis 
are not found in any other mental disorder. The mannerisms in writ- 
ing, neologisms, and reiterations of dementia prsecox are also character- 
istic. Furthermore, such letters may reveal the presence of delusions 
not easily elicited from the patient in conversation. 

Examination of the Patient's Physical and Mental Condition. — 
The following points should be investigated as to the general physical 
condition : 

1. General nutrition — atrophy, hypertrophy. 

2. Stigmata of degeneration. 

3. Skin — old eruptions, scars, cicatrices on penis, mucous patches, 
bed-sores, swellings, cyanosis. 

4. Lungs and heart, pulse, circulation. 

5. Blood — pressure, hemoglobin, parasites, differential count. 

6. Genito-urinary system, urinalysis. 

7. Gastro-intestinal system, stomach and fecal tests if indicated. 

8. Osseous system. 

9. Abdominal viscera. 
10. Sleep. 

The examination of the condition of the nervous system should give 
information on the following points : 

1. Beflexes — pupillary and tendon. 

2. Special cranial nerves — olfactory — optic (hemianopsia, limitations 
of visual field, color, fundus) — oculomotor (diplopia, nystagmus, prop- 
tosis, ptosis) — taste — hearing. 

3. Common sensation — anesthesias, paresthesias, hyperesthesias, 
stereognosis. 

4. Motor symptoms — paralysis, or morbid movements, gait, ataxia, 
etc. 



762 MENTAL DISEASES. 

5. Speech — any form of dysarthria, or any species of sensory or 
motor aphasia. 

The psychic investigation then begins with a study of the patient's 
orientation. His orientation as regards himself is determined by his 
answers to the following questions : 

1. What is your name? 

2. How old are you? 

3. What is your occupation ? 

4. Where do you live ? 

5. Where were you born ? 

6. When were you born? 

Then his orientation as to time is ascertained by asking : 

1. What year is this ? 

2. What day is this? 

3. What is the date and the month ? 

4. Is this summer or winter ? 
Orientation as to place is elicited by asking : 

1. What place is this you are now in? 

2. What city is this ? 

3. Where is your home? 

4. Can you name any of the people about you ? 

Complete disorientation is observed in some acute psychoses, like 
some epileptic conditions, acute hallucinosis, and febrile and alcoholic 
deliria, and also in states of profound dementia. Partial disorientation 
is found in a variety of other psychoses. 

To determine whether the patient has any insight into his own dis- 
order we may ask him : 

1. Is this your home? 

2. Is this a hospital ? 

3. Why are you in a hospital? 

4. Are you sick? 

5. Is anything particular the matter w T ith you? 

6. Is there anything the matter with your brain or mind ? 

The memory must be tested by all sorts of questions dealing with the 
whole past life of the patient, questions relating to childhood and youth, 
the family, the schools attended, the studies carried on, the occupations 
followed, and so on, in order to determine whether the memory-store for 
the whole past is intact to date ; secondly, whether there are periods of 
time in which memory-material is missing (certain lacunae of memory), 
and, lastly, whether there is any failure in the power to add to the old 
store of memories. This last has to do with recent memory material. 
The Germans call this power to increase the store of memories Ilerk- 
fahigkeit. 

Simple tests of memory may be made by having the patient write an 
autobiographical sketch, by questioning him in relation to school studies, 
geography, history, religion, literature, by giving him sums in mental 
arithmetic, by having him repeat old and familiar poems learned at 
school, and by having him recite the alphabet, Lord's prayer, names of 
the months, etc. 



METHODS OF EXAMINATION. 763 

Defects in memory are often observed early in paresis, and are con- 
stant in senile dementia (especially memory for recent events, the old 
being well preserved), while in KoraskofPs psychosis the loss of the 
power of adding to the memory-store is a cardinal symptom. Amnesias 
are particularly characteristic of epilepsy. Fabrication or confabulation, 
which is a sort of hallucination of memory, the patient trying to fill up 
gaps in his remembrance by all sorts of remarkable stories, is a symptom 
found in various kinds of insanity, particularly in some paranoid condi- 
tions, in general paresis, in delirium tremens, in Korsakoff's psychosis, 
and in certain manic and senile cases. 

To test the intelligence we have already had the autobiographical 
sketch, and the answers to questions relating to the whole early life of 
the patient, but to these tests we must add the following : 

1. Have the patient write one or more brief essays on any subject 
which the examiner thinks him competent to deal with. 

2. Write a letter. 

3. Draw pictures of objects from memory. Make a map of some 
country with which he is familiar from memory. 

4. Try the word-association method, although this is not as impor- 
tant as a test of intelligence as it is of emotions. Still it has a certain 
value in showing often a richness of association not found among unin- 
telligent individuals. 

The Word-association Method. — While the word-association method 
is of some use for the purpose for which it was first employed, viz., to 
estimate the intelligence of an individual, it is of even greater value in 
uncovering emotional complexes. The subconscious is vastly more im- 
portant to us than the conscious, for in the subconscious lie all the 
elements that make up our personality, not only the treasury of all our 
individual experiences through the course of years, but all our ancestral 
trends, desires, tendencies, wills, ambitions, controls, inhibitions, fears, in 
fact, the latent spirit of the race of mankind. 

Each man's vocabulary, be it the three hundred words of the sailor 
or the fifteen thousand words of a Shakespeare, or the average fifteen 
hundred or two thousand words belonging to us, is related to all that 
subconscious material. A word has a magic power in it to summon from 
the vaults of memory all sorts of apparitions. Each word has an emo- 
tional value, some more than others, because all of our deepest experiences 
are associated with the words we know. 

So when an apparently empty word is propounded to a patient, and 
he is asked to answer with another word as quickly as possible with the 
first word that comes into his mind, we not only obtain an association 
from his memory storehouse, but we may strike some emotional complex 
which is indicated by a slow response to the test word or retarded 
reaction time. 

This is the word-association method of Jung, a method that is em- 
ployed for the discovery of secrets in the criminal, or painful and disease- 
producing emotional complexes in patients suffering from various 
psychogenic disorders. In making this test just ordinary, everyday 
words are used, since these are the especial words related to an ordinary 



7(34 • MENTAL DISEASES. 

individual's experiences, and a fifth of a second stopwatch is used to 
measure the reaction time. An emotional complex is so apt to have 
many words associated with it that there is an inrush of many words to 
the stimulus word, and the mind pauses for a choice ; hence the retarded 
reaction time. Having gone over the list once with a stopwatch, we go 
over the same list of words again to see how well the first associations 
are remembered. The inrush of words is responsible for faulty memory 
here, and where there are emotional complexes, these reproductions are 
apt to be false, some new word being associated the second time. 

Thus, a patient was given a series of unimportant words that had no 
significance whatever to the investigator, and among them the following 
had three or four times as long reaction time as the others, so that it was 
clear that an emotional complex lay behind them : Water — deep, 5 
seconds ; ship — sink, 3.4 seconds ; lake — water, 4 seconds ; swim — can 
swim, 3.8 seconds. 

Psychanalysis showed that the patient had recently been depressed, 
and had determined to commit suicide by drowning. 

In making up our list of words, we select the most common words in 
everyday use, and propound them in series of twenty-five to fifty or a 
hundred. It is well to vary the character of the words in the list by 
writing down a noun, an adjective, a noun, a verb, and so on, rather 
than to make the series all of one grammatical genus. Here and there 
in such lists words thought to have special significance to the patient 
may be introduced. 

The Galvanometer as a Measurer of Emotions. — We may employ 
a Deprez-d'Arsonval galvanometer at the same time with the word- 
association test, and the fluctuations of the galvanometer in propor- 
tion to the extent and reality of the emotions is important in corrob- 
orating the evidence given by retarded reaction time and false 
reproductions. One or two cells are placed in the circuit with the 
galvanometer and the patient, who has his hands upon metallic plates. 
Emotions stimulate the sweat-secretory glands, and by thus reducing 
resistance in the circuit, determine fluctuations of the galvanometer 
mirror. A light thrown upon the mirror is reflected upon a measured 
screen concealed from the patient, and the extent of deviation may be 
accurately estimated and set down. The whole procedure and the results 
in normal and insane persons were fully described in Brain, August, 
1907, by Jung and myself. 

Psychanalysis. — This method of psychological study of a patient, 
developed by Freud, is more often applicable to cases of hysteria and 
psychasthenia than to insanity, but it is frequently of use in minor 
psychoses. Freud's technique is as follows : 

The patient lies quietly on a sofa in order to be tranquil and to 
avoid physical or other distraction. The physician sits at his head, and 
may at times place his hand upon the patient's forehead, a physical 
stimulus which often assists the patient in concentrating his attention 
upon the subject in mind. This may be and often is some emotional 
complex. buried too deeply in the mind to rise readily into consciousness, 
some emotional experience having a causal relation to the psychoneurosis. 



METHODS OF EXAMINATION. 765 

Perhaps the word-association test has already been used, and clues thus 
afforded for this additional investigation. The patient is urged to talk 
freely and frankly about his symptoms and their origin. Often the 
memory is found to be at fault, and he is requested to tell everything 
that passes or comes into his mind, even if painful and embarrassing. 
We may utter some significant word known to be a clue, and then ask 
him what thoughts occur to him in connection with the words. We may 
also ask him to repeat to us his dreams, and from these, which have their 
being in the subconscious, we also draw material for our purpose. The 
object of such psychanalysis is twofold. In the first place we may 
uncover the details of some psychic trauma which is usually at the basis 
of most hysterical manifestations and of many psychoneurotic conditions, 
such as obsessions, phobias, and the like, and may be the origin of some 
type of insanity, like dementia prsecox. In the second place, it is a 
therapeutic procedure, and the psychanalysis ordinarily cures the patient. 
There is a psychological mechanism associated with all painful, unendur- 
able emotions. Either the emotion is reacted to adequately at the time, 
as in normal grief, or it is intentionally suppressed. The intentional 
suppression is helped by the wish and struggle to forget. If one receives 
an insult and knocks the giver down, this is an example of an adequate 
and satisfactory reaction to a disagreeable emotion. If one is obliged to 
" pocket the insult," a very good expression for the mechanism in ques- 
tion, it will rankle indefinitely, perhaps for years, in one's bosom, sup- 
pressed, possibly forgotten, but liable at any time to light up by sudden 
association of place or face or word. Suppose a child is assaulted, a 
young woman jilted on the eve of marriage, a young man overhears 
some jeering remark concerning himself — these are psychic traumata 
which, without adequate reaction, may become suppressed emotional 
complexes acting like a parasitic body on the psyche, drawing all sorts 
of associations to itself, and finally, by a process of conversion, may 
react upon the physical organism, inducing hysterical pains, anesthesias, 
palsies, and the like. If by psychanalysis we are able to reawaken the 
old painful memories and discuss them with full circumstance and detail, 
with free play of the emotions, the hysterical and other psychoneurotic 
symptoms disappear. This abreaction, or reacting off, has for ages been 
taken advantage of by the confessional of the Catholic Church, those 
wise fathers long ago recognizing the psychological fact that a secret 
remorse, pain, or grief, unburdened to another, lifts the load from the 
penitent and suffering. 

The Study of Patients 9 Dreams. — It was Schopenhauer who said 
that insanity is a long dream and a dream brief insanity. There is, 
in fact, more than a superficial resemblance between dreams and insan- 
ity — so much so that psychiatrists the world over are devoting themselves 
to the study of dreams as a part of their clinical and scientific work. 
There is practically no phenomenon that presents itself in dreams that 
we may not observe among the inmates of an asylum ward. There are 
in both mental disease and dreams a prominence of visual and auditory 
hallucinations, a tendency to the reproduction of old experiences, the 
imaginary fulfilment of wishes and desires, baroque associations, chaotic 



766 MENTAL DISEASES. 

flight of ideas, incoherence, disorientation, weakened judgment, and 
division of personality. 

Sometimes insanity first manifests itself in dreams, though the mind 
is still normal by day. In alcoholism dreams sometimes foreshadow the 
characteristic alcoholic delusions (of infidelity, etc.), and dreams may be 
the equivalents of epileptic seizures. Sometimes in patients just recov- 
ered from insanity who are normal by day there is a nightly recurrence 
of insane delirium in sleep — a species of nocturnal insanity. A terrible 
dream may usher in insanity, which then concerns itself with the mate- 
rial created by the dream. Dreams at times induce the imperative ideas 
and impulses of psychasthenia. Thus, in a way, we may look upon 
insanity, in itself a pathological condition, as a summation of periodically 
recurring normal dreams, as a kind of reduction of consciousness, such 
as exists in the dream state. 

Freud has written a fascinating book on the Divination of Dreams. 
I can only describe briefly what his views are. In the first place, 
dreams always seem to be the fulfilment of some wish or desire. In 
children this is invariably true, as will be found by a little investiga- 
tion. The child receives in dreams the delights that he longs for. 
When a dream is recorded and examined, we have before us a curious 
piece of conglomerate, often uniting materials from the days of child- 
hood with experiences of yesterday, full of absurd distortions of events 
and words, transformations, allegories, and symbols. There is nothing 
accidental in the arrangement, and by psychanalysis of the person hav- 
ing the dream, one determines the origin of every patch in the crazy- 
quilt ; and by investigation one discovers the wish at the foundation 
which is directly or indirectly fulfilled by the dream. Freud has been 
much criticised because in his opinion it is usually a sexual idea which 
is the fons et origo of these dreams, as well as of hysteria and other 
psychoneuroses. Doubtless he has gone to extremes in this idea, but 
he has certainly opened up a very important field and discovered new 
methods of approach in the domain of morbid psychology. 

There are also methods of studying the attention, apprehension, apper- 
ception, and morals, and for eliciting information as to the presence of 
illusions, hallucinations, and delusions, but in the conduct of an exam- 
ination of a mental case, as described in this chapter, much will present 
itself to throw light on these other qualities and symptoms. 



GENERAL TREATMENT OF INSANITY. 767 



CHAPTER V. 
GENERAL TREATMENT OF INSANITY. 

It is not so long a time since the insane in Christendom were be- 
lieved to be possessed of devils and accursed. On the other hand, in 
certain parts of heathendom (among the Mohammedans) it was sup- 
posed that the souls of the insane had been removed early by God as a 
special mark of favor, and that they were, therefore, blessed. Medieval 
treatment was founded upon the curious pathology just described. One 
portion of the world ducked, whipped, tortured, chained in dungeons, 
and occasionally burned, the insane. The heathen treated their insane, 
upon the whole, comparatively well. 

After a time, many of the therapeutic measures employed by the 
Europeans of the middle ages were abandoned as unsatisfactory. But 
society still had to be protected ; so the insane were fettered in the cells 
of jails and fortresses and solitary towers, until a realizing sense of the 
inhumanity of such treatment struck a responsive chord somewhere in 
the breast of a Tuke, a Connolly, a Pinel, a Rush, a Kirkbride, an 
Earle, and doubtless other, but unknown, immortals both before and 
after them. 

Insanity thus gradually came to be looked upon as a disease, and 
not a penal offense, and, instead of prisons, special buildings were set 
apart for the particular custody of the insane. The great object of the 
asylums at first was to afford protection to society from lunatics, to pro- 
tect them from themselves, and to provide for their care and support, 
when at public cost, in an economical manner. A hundred years ago, 
however, the asylum was still a species of jail, for its evolution had not 
yet proceeded far. Dungeons and iron chains and staples in stone 
walls and stone floors were still in use in many places. Indeed, it is 
scarcely over eighty years since JSTorris, a patient in Bedlam (Bethlehem 
Hospital), hi the great Christian city of London, was kept for twelve 
years in a cell, with an iron collar riveted around his neck and iron 
bands and rings around his wrists, arms, and ankles, the neck being 
fastened to the wall and the leg to a rude box of filthy straw. 

Asylums have, at the present time, come to be recognized as hos- 
pitals, and they are approaching nearer to that ideal every year. 
Occasionally, one finds among them some rudimentary appendage which 
is reminiscent of the embryonal stage of their evolution ; but this is, 
fortunately, rare. The well-conducted hospital for the insane, to-day, 
is different from the asylum of years ago ; the depressing, barren halls 
and wards and naked floors have given place to pleasantly furnished 
and carpeted, cheerful-looking parlors, sitting-rooms, and bed-rooms ; 
muffs and strait-jackets have disappeared ; the unintelligent attendant 
has, in many instances, given place to the trained nurse ; every new 



768 MENTAL DISEASES. 

means of treatment is carried out to the best of the ability of the 
asylum physicians ; schools, employment, theatricals, music, and out- 
of-door walks are provided in the place of the old, deadly monotony, 
and, in fact, the asylum has gradually undergone a metamorphosis, 
until its character has completely changed. There are, to be sure, not 
many perfectly ideal institutions as yet in existence, but there are some 
which approach very nearly to it, as, for instance, that at Alt-Scherbitz, 
near Leipzig, and the new asylum at Rome, both of which I visited 
and described in 1887. 1 These are, of course, constructed on the cot- 
tage and pavilion plan, so arranged as to impress one as small colonies 
or villages, with separate buildings for those merely there for custody 
because of dangerous propensities, those brought there to be cared for 
kindly during the remainder of their useless lives, those who carry on 
various occupations, and, finally, for such as enter particularly to secure 
treatment for the brain-malady which has bereft them temporarily of 
their reason. The colony system of caring for the dependent classes — 
which the writer thinks should ultimately be adopted for all kinds of 
defectives — is well exemplified by the Craig Colony for epileptics in the 
State of New York. Some day we shall come to realize in all our 
hospitals and retreats for the insane, it is to be hoped, the ideals already 
exemplified in two unique institutions for the insane, which are not as 
well known as they deserve to be. One is the Maison de Falret, at 
Vanves, in the outskirts of Paris, established nearly one hundred years 
ago by a famous alienist, the other, singularly enough, is at Iwakura, 
Japan, and was founded almost a thousand years ago, with a history 
and evolution similar to that of Gheel, in Belgium. I have described 
both of these institutions in a paper read in 1910 before the National 
Conference of Charities, published in the transactions for that year. 

I will say that I believe improvement and reform are constantly 
going on in asylums throughout the world ; that no one is more anxious 
than are their superintendents to make progress in the care and manage- 
ment of the insane. They are rapidly reaching the best methods of 
dealing with the insane poor. If any are tardy in this advance, it is 
because they are so often hampered by the never-ending overcrowding 
of our public asylums, by the interference of politics, by the lack of 
money, by the want of a sufficient number of medical assistants, and by 
a multiplicity of official duties. 

While these statements are undoubtedly true, — and great credit is due 
the asylum physicians of the present day for their strenuous efforts in 
behalf of their charges, — I believe that the ideal treatment of almost any 
insane person is to be sought outside of an asylum. After an asylum 
experience of some years, and an experience of many years, too, in 
private practice, I feel that I am in a position to judge fairly well of 
the relative merits of treatment in and out of asylums. 

Theoretically, it ought to be the right of every individual in sickness 
to receive the best treatment that medical science affords ; but this right 
can be enjoyed by very few. There are too many interfering condi- 
tions. Not every injured man is within reach of the best surgeon ; not 
1 "Some European Asylums," " Amer. Jour. Insanity," July, 1887. 



GENERAL TREATMENT OF INSANITY. 769 

every fever-stricken one convenient to the best physician ; and few are 
the deaf, the blind, the lame, those with crippled bodies and those with 
disordered minds, who ever really receive the best treatment that the 
world can give. The intelligent doctor and the scientific skill are not 
the only requisites. Other conditions are good nursing, the most suit- 
able climate, the best hygienic surroundings, the best moral atmosphere. 
In dealing with affections of the body solely, there is often much to be 
desired; but it is particularly in the treatment of those who are men- 
tally as well as physically afflicted that so much which should be done 
is left undone. The obstacles in the way of securing the best treatment 
are multiplied in the case of the insane by the dethronement of the 
supreme centers of psychic function. 

Just as a hospital is a better place than a tenement house for a sur- 
gical patient or a case of fever, so is the asylum superior to the home 
in the caretaking of the pauper and indigent lunatic. The acutely 
insane of the poorer classes are best treated, at present, in our large 
public institutions ; and those among the moderately well-to-do, either at 
home or in the small private asylums. Only the insane of the wealthy 
classes can, perhaps, enjoy and carry out ideal methods of treatment in 
their own homes, in country houses, or in foreign travel. 

It is, of course, needless to say that there are many degrees of 
insanity ; that there are hundreds of cases that are never obliged to go 
to an asylum at all ; that in society are many insane persons carrying on 
legitimate occupations and caring for themselves and families ; and that, 
on the other hand, there are cases for which nothing but commitment 
to an asylum would be suitable or feasible. But we should not send 
any patient to an asylum unless he needs restraint because of danger 
to himself or others, or because proper treatment and supervision are 
difficult in his home, owing generally to poverty or other insurmountable 
conditions. The sooner a case of acute insanity occurring in a pauper 
or an indigent is removed to an asylum, the better are his chances for 
recovery. This merely signifies that the earlier treatment is undertaken 
by those who are familiar with the management and care of the insane, 
the better for the patient. Early treatment by physicians of experience 
in psychiatry is demanded. At present this end is best attained by 
resort to the asylums of the neighborhood. But the writer has often 
called attention to the need of increasing and extending the facilities 
for the early treatment of the insane — a matter which can be accom- 
plished in several ways. The lines of progress in such direction are : 

(1) The opening of special reception-wards or pavilions for the 
insane in general hospitals ; (2) the establishment of psychopathic hos- 
pitals in large cities ; (3) the creation of outdoor departments in con- 
nection Avith asylums situated in densely populous districts. 

Before taking up the matter of the treatment of insanity, a few 
words should be said as regards 

Prophylaxis. — Naturally, the question of the proper care and edu- 
cation of children with a tainted line or lines of ancestry often comes 
before the physician. Much can be done to ward off impending future 
evils by due and early attention to the mental and physical evolution 

49 



770 MENTAL DISEASES. 

of such children. One can not begin too soon to regulate the life of 
these little ones. The very milk of a weak and anemic mother may 
diminish the feeble resistance of a degenerate child. From the day of 
birth the prophylaxis must begin. The points to be observed in the 
effort to accomplish this are as follows : 

1. Cultivate the body of the growing child. Develop him physi- 
cally by careful and regular diet, regular hours of sleep, outdoor life, 
efficient systems of exercise. 

2. Let his training be muscular rather than intellectual, manual 
training rather than lessons, especially in the early years of childhood. 
No schools until the age of seven or eight years. 

3. The child with degenerate tendencies should be forbidden all 
nervous stimulants, such as tea, coffee, wines, beer, tobacco. 

4. Seek to develop the resistance of the organism to all external 
stimuli, hardening his body by the daily morning cold bath, frictions, 
exercise, a hard bed, a cold sleeping-room ; accustoming his mind to 
the courageous endurances of pain and mental stresses. 

5. Guard well the epoch of puberty. 

6. Let the occupation chosen for later years be also one for the 
muscles rather than for the mind, an outdoor rather than an indoor 
calling, a country rather than a city life. 

Many of our States and many other countries are taking up very 
seriously the question of the prevention of insanity, either through various 
charitable bodies or through the activities of societies first founded for 
after-care of the insane. The after-care societies have broadened their 
field of work in many cases by adding fore-care, or prevention, to their 
functions. It would seem as if more than 40 per cent, of insanity could 
be prevented by the eradication of alcohol and syphilis alone as causes. 
By the crusades and public education now being carried on everywhere, 
there is no doubt that there will be a gradual diminution in insanity 
due to these causes. It is possible that the discovery by Ehrlich of 
salvarsan may lead to a more certain means of destroying the germs of 
syphilis, and, while as an aid in the treatment of paresis it is apparently 
of no use, as a means of prevention of paresis it may prove successful. 

Isolation. — On being called to see a patient suffering from insanity, 
the first point which arises is whether he should be sent to an asylum 
or not. This is generally a question of means. Isolation from the imme- 
diate friends is in nearly every case a requisite. If the patient belongs 
to the indigent or to the middle classes, isolation and the best treat- 
ment for his malady are only to be satisfactorily obtained in an asylum 
or hospital for the insane. Among the well-to-do, the needed isolation 
may be successfully secured in his own house, in an ordinary sanatorium, 
or by means of travel with a suitable nurse, companion, or physician. 
The kind of treatment best adapted to the nature of the case must be 
decided by the physician. The quiet of a private house in the city or 
country is best for some cases, while the tonic and stimulus of foreign 
travel are indicated in others. It may be stated that, when travel seems 
to be the prescription required, the greater the change from the envi- 



GENERAL TREATMENT OF INSANITY. 77J 

ronment in which the mental disorder developed, the better. The 
cities of Great Britain and the Continent do not differ essentially from 
our own cities, and patients should not be sent to such places with the 
idea of securing a change of environment. Norway in summer, Egypt 
in winter, and Mexico in either summer or winter, are regions which 
offer the greatest inducements in the way of tonics to the nervous 
system and stimulus to the mind, and all three are, at the same time, 
peculiarly restful and calmative. 

If these methods of home, country house, or travel are for any 
reason impracticable, then the smallest private asylum that can be found 
is to be selected, for the fewer other insane persons and the greater num- 
ber of sane persons the patient comes in contact with, the better will be 
his chances for recovery. There is a need for physicians in practice in 
the country who will be duly authorized and empowered by law to 
receive in their own homes and care for one such patient. The chief 
drawback in home-treatment, if long continued, is usually the bad effect 
of association with an insane person upon other members of his family, 
particularly if they be neuropathic. With a sufficiency of nurses and 
room, there is no contingency in the treatment of the insane that can 
not be guarded against. These being provided, the worst features in a 
case, such as violence, homicidal and suicidal tendencies, attempts at 
self-mutilation, etc., may be as well avoided outside as inside of an 
asylum. There are cases in which — though I am opposed to mechanical 
restraint in great measure — I should employ long-sleeved night-gowns, 
or even camisoles, rather than let them go from home before all means 
of cure had been tried at least for a few weeks' time. 

The conditions and propensities that we have to combat are many. 
The choice of method must be the result of careful deliberation, and after 
judicial survey of all the features presented. We usually need the 
assistance of skilled and experienced nurses. Thanks to the asylum 
training-schools, there are numbers of such trained nurses of both sexes 
to be had in our large cities. 

Psychotherapy. — Isolation and psychotherapy may be set down 
as the great cardinal principles in the treatment of the insane. Under the 
heading of psychotherapy are included, not only the influence of sane 
companionship with the best nurses obtainable, and the conversations 
with them and the medical man in charge of the case, but all sorts of 
exercises and occupations. One must remember that the cases of acute 
insanity requiring bed treatment are in reality rare. The vast majority 
of the cases are rather subacute, insidious, chronic in their onset and course. 
It is an axiom with the psychiatrist that nothing is better in the way of 
treatment for the disordered mind than physical employment, which im- 
proves nutrition, acts as a safety-valve for the escape of surplus energy, 
distracts the attention and engages the interest of the patient. Unfor- 
tunately this system of psychotherapy is seldom well carried out anywhere 
in public or private asylums. In public hospitals its inadequacy is due 
chiefly to lack of money to furnish the necessary teachers of industries, 
arts, and crafts. In private retreats, the money is not lacking, but the 



772 MENTAL DISEASES. 

disposition to use it is absent. The habit of keeping only a boarding- 
house for the insane is a hard one to break. It is probably true that the 
doctors in charge of private retreats are not wholly responsible for the fact 
that they do little for their patients beyond feeding, housing, and guard- 
ing them. The defect is partly due to long-established custom, partly to 
therapeutic pessimism, and partly to the stand taken by patients' relatives 
who are not yet educated to the occupation-idea. In the ideal sanitarium 
for mental cases the indoor and outdoor sports and exercises should be 
developed to the farthest possible point, under the supervision of a com- 
petent director, while teachers of arts and crafts should preside over the 
handicraft shop, and other instructors should be employed for industries 
of various kinds, such as agriculture, carpentry, floriculture, gardening, and 
the like. The system has been well developed at the Craig Colony for 
Epileptics. Among the arts and crafts that should be taught in every 
institution for the insane are wood-carving, leather-work, tapestry-weav- 
ing, basket-work, pottery, brass-work, drawing, designing, painting, and 
outdoor photography. Every alienist with imagination knows how very 
far we are as yet from an ideal standard of care of the insane. But we 
have corroborative evidence from the side of the patients themselves, as, 
for instance, in "The Mind that Found Itself," by Clifford W. Beers, who 
was a patient in several institutions for the insane, both public and private 
(Longmans, Green & Co., 1908), a book which every "friend of the in- 
firm in mind" should carefully read. See also page 778 on moral treat- 
ment. 



TREATMENT OF ACUTE CASES. 

In acute cases, whether of mania or melancholia, it has been my 
experience that confinement to bed is a valuable factor in cure. Hence, 
on being called to such a case, I have the patient put to bed. Due 
precautions are taken as to the removal of all sharp instruments, 
weapons, drugs, cords, door-keys, and the like, and by a simple device 
the windows so arranged that they may not be opened beyond six 
inches ; otherwise the furnishings may be left as they are without 
attention. 

Insomnia and mental and motor excitement most frequently demand 
our best skill. In emergency, I am in the habit of using duboisin 
sulphate hypodermatically in the dose of y^-g- of a grain, or sometimes 
hyoscyamin, or hyoscin hydrobromate in doses of from y^ to -^ of a 
grain hypodermatically, though these latter are not so satisfactory as 
duboisin. But for routine treatment of insomnia and maniacal excite- 
ment I much prefer hydrotherapy to drugs. In some cases the pro- 
longed warm bath (70°— 90° F.) for from one-half to two hours may be 
used, but in all cases the hot wet-pack is applicable. Sometimes when 
the wet-pack does not suffice to quiet fierce maniacal excitement, I use 
duboisin in addition, or give doses by the mouth of paralclehyd, trional, 
and sulphonal, all of which are valuable hypnotics. 

In acute depressed conditions, on the other hand, opiates usually act 



GENERAL TREATMENT OF INSANITY. 773 

best in cases in which hydrotherapy does not subdue the insomnia, dis- 
tress of mind, and disordered nervous system. Among opiates, codein 
seems to offer advantages over others, and the contraction of a habit 
need not be feared. The aqueous extract of opium or morphin may 
be given hypodermatically. 

The refusal of food is another element of danger. Acute insanity, 
besides rest in bed, quiet, and repose, needs overfeeding to balance the 
great waste of tissue going on in the system. While many cases of 
acute mania w T ill eat and drink ravenously at times, from the nature of 
things their actions are uncertain, and the nurse should be instructed 
to feed the patient almost hourly and keep account of wdiat is given. 
Milk, raw eggs, meat-juice, and occasional stimulants must, in extreme 
cases, be our chief reliance. Having an intelligent and assiduous nurse 
at hand, the necessity of feeding with a tube will only rarely occur. 
When required, the soft rubber stomach-tube may be introduced by the 
physician through the mouth or nose, a funnel attached, and the liquid 
mixture of the substances named allowed to flow in. 

There are cases (some of the insanities of puberty and adolescence, 
and other forms) in which anaphrodisiacs modify distinctly the trend of 
delusions. There are cases in which intestinal antiseptics achieve note- 
worthy results ; indeed, the instances are few in which attention to 
morbid states of the alimentary canal is not rewarded by considerable 
benefit to the mental condition of the patient. Argument with patients 
upon delusions, more or less fixed in character, often has, despite the 
opinions of numerous alienists to the contrary, decided value in altering 
their beliefs, and at times even eradicating their insane ideas altogether. 
It is true that occasional argument is generally of no avail. Such moral 
treatment must be sedulously and perseveringly employed, daily and for 
weeks or months, to insure success. Argument is a species of sugges- 
tion. The tactful and judicious physician will not make use of it in 
cases where it leads to irritation and would seem to be injurious. 

The most important remedial agents employed in insanity are as 
follows : 

The Rest-cure. — This has already been briefly referred to. It was 
in 1860 that Hilton began his series of lectures on rest and pain, in 
which he pointed out how much rest had to do with growth and repair 
of the bodily tissues, and fifteen years later Mitchell wrote of the value 
of rest in the treatment of hysteria and neurasthenia. ^Nowadays, 
however, we apply the principle of rest to a great variety of nervous 
disorders. Besides its indication in many cases of hysteria and neuras- 
thenia, we find it of the greatest benefit in all sorts of nervous and 
mental troubles, and especially in such as evince a tendency to waste of 
tissue and to exhaustion. 

Most cases of acute mania need to be treated by rest, which should 
be made as absolute as possible. Many cases of acute melancholia 
recover more quickly when confined to bed. While in many mental 
cases the rest should be absolute for a period of several weeks in order 
to insure a successful termination, it is astonishing how much benefit 
can be obtained by a modified rest treatment — that is, by merely pro- 



774 MENTAL DISEASES. 

longing the daily amount of repose in bed. The principle is to apply 
rest methodically, and in proportion to the degree of nervous exhaus- 
tion, strain, or irritation. 

When rest is made nearly absolute, it is necessary that tissue meta- 
bolism should be encouraged by attention to the amount and quality 
of food, and especially by substitution of some passive artificial exer- 
cise for the active movements upon which the organism has hitherto 
depended. This is accomplished chiefly by massage. 

Massage. — Massage was a favorite remedy and luxury in ancient 
Roman times, when it figured as the Aliptic Art ; 1 so that it is not at all 
a new remedy, but its vogue in recent years has assumed enormous pro- 
portions, and it has received a scientific study and systematization to 
which the ancients were strangers. This rubbing, beating, and knead- 
ing of the trunk and limbs, when skilfully done, is an essential adjunct 
to the absolute rest treatment. It is invaluable in many kinds of pain, 
and it often surpasses drugs as a soother of irritation and an inducer of 
sleep. 

Diet. — It is needless to say that in connection with a form of rest 
treatment simplicity should be the rule as regards food. The selection 
should be made from the point of view of easy digestibility, and fore- 
most in this regard stand milk and its various preparations. Where 
milk can not be taken in its ordinary form, some more digestible prepa- 
ration may be employed, such as peptonized milk, koumiss, ruatzoon, 
or somal. In cases undergoing a rest treatment this is the main staple 
of food, and it should be given frequently and in considerable quantity. 
Overfeeding is indeed another principle in the treatment of any of the 
nervous and mental diseases in which exhaustion is a feature. Thus, 
absolute rest and overfeeding must be our chief reliance in acute mania, 
and in severe types of melancholia. Many cases require feeding every 
hour or two hours. Raw or soft-boiled eggs, rare or raw beef, specially 
prepared cereals, and sometimes green vegetables and fruits may be 
added to the diet. (By specially prepared cereals I mean simple boiled 
rice, stale bread in the form of toast, or, better, bread which has been 
twice baked — Zwieback). Stimulants are only occasionally indicated, 
and then especially in acute maniacal or other dangerously exhausting 
conditions. 

A somewhat similar form of diet is appropriate for mental disturb- 
ances having a rheumatic or gouty diathesis as a basis. The same diet 
is essential in all cases of insanity, neurasthenia, epilepsy, and so on, 
which seem to depend upon auto-intoxication from fermentative or 
putrefactive changes in the intestinal contents, and such cases we find 
nowadays to be not at all infrequent. 

Hydrotherapy. — When in 1893 I wrote a paper on " Hydrotherapy 
in the Treatment of Nervous and Mental Diseases " (" Amer. Jour, of 
the Med. Sciences," February, 1893), there was really no place in the 
city of New York to which one could send patients and have his own 
ideas as to treatment faithfully carried out ; nor did I know of a single 

1 "The Aliptic Art : a Historical Study," by the author, "Phila. Med. News," 
Aug. 11, 1883. 



G ENERAL TREATMENT OF INSANITY. 775 

asylum for the insane in this country installed with hydrotherapeutic 
apparatus, such as I had seen in a number of asylums abroad, even 
in so remote a country as Greece. Now I could name many public 
and private asylums which are equipped with arrangements for this 
purpose. 

Water affects the nervous system in a variety of ways. 

Cold baths increase and warm baths diminish the irritability of the 
brain and spinal cord in a reflex manner by stimulating the sensory 
and vasomotor nerves of the skin, thus influencing the cerebrospinal 
circulation. 

For some years they have been using in German asylums the con- 
tinuous bath for cases of excitement. The patients stay day and night in 
these baths, sometimes continuously for weeks or even months. Occa- 
sionally the continuous bath is used only for five, six, or eight hours per 
day. The water is kept at a comfortable tepid temperature. No very 
serious skin disorders are produced by such prolonged immersion, and the 
method is well adapted to cases of excitement. 

Short cold baths, especially when combined with sprinkling, shower- 
ing, or rubbing, are powerfully stimulating, exhilarating, and tonic. 
Cold baths stimulate peristalsis and the visceral reflexes in the cord, 
and increase blood-pressure. Prolonged warm baths, steam and hot- 
air baths, and the hot pack are relaxing, fatiguing, and tend to induce 
sleep. Warm baths diminish arterial tension and reduce the irritability 
of individual nerves and the whole nervous system. The spinal douche 
is of the greatest service in many nervous disorders, because of its re- 
markable tonic, revulsive, and derivative effects. It is a powerful 
mental as well as physical stimulus. By means of various nozzles it is 
ejected in the form of a strong stream up and down the back of the 
patient for a few seconds only, at a distance of some ten feet. Patients 
with good reaction do not need any special preparation, but at the 
beginning it is well to have the patient take a warm bath or stay a few 
minutes in a hot-air box previous to its application. At the first 
seances the water should not be too cold. Later, it may be gradually 
lowered to 50° F. It should be taken every day, when possible. Oc- 
casionally this cold spinal douche is alternated with a hot douche (the 
so-called Scotch douche). This is an exceedingly successful procedure 
in many cases of hysteria, neurasthenia, and in lethargic and hysterical 
forms of insanity, where there are sluggish intellect, great depression, 
apathy, stupor, catalepsy, etc., and in any case of nervous and mental 
disease where anemia, chlorosis, or gastric trouble exists. 

In insomnia there is no other remedy so generally efficient and at 
the same time so innocuous. I have seen it successful in wake- 
fulness from every kind of cause, and in cases seemingly intractable 
to other remedies. There are two hydriatic procedures for the 
production of sleep. One is the prolonged warm Avhole bath, at a 
temperature of 70° to 90° F., for from one-half to two hours just before 
retiring. This is indicated in mild cases of insomnia. But the hot 
wet-pack is more effectual and more widely applicable in all forms of 
sleeplessness, whether in nervous or insane individuals. It is applied 



776 MENTAL DISEASES. 

in this way : A blanket, nine by nine feet, is spread upon the patient's 
bed, and upon this a sheet, wrung out dry after dipping in hot water, is 
laid. The patient lies dowu upon this, and the sheet is at once evenly 
arranged about and pressed around the whole body, with the exception 
of the head, after which the blanket is also immediately likewise closely 
adjusted to every part of the patient's body. Other dry blankets may 
now be added as seems necessary. The patient remains in this an hour 
or longer ; all night, if asleep. 

I know of no better treatment of acute maniacal conditions, for 
instance, than rest in bed, overfeeding, the hot wet-pack, and the occa- 
sional employment of some sleep-producing agent. 

Treatment of Auto-intoxication. — Researches in the physiologi- 
cal chemistry of digestion, as well as observations in many pathological 
conditions, have established that auto-intoxication from the absorption 
of poisonous substances generated in the alimentary canal by putre- 
factive and fermentative processes, or in the various tissues of the body by 
a perverted chemistry, is not only a real thing, but a frequent factor in the 
etiology of a number of nervous disorders, such as headache, neurasthenia, 
hysteria, neuralgia, and even graver maladies, like epilepsy, melancholia, 
mania. It behooves us, therefore, in these diseases, to investigate care- 
fully for evidence of any such cause. Periodical or constant attacks of 
gaseous diarrhea are somewhat indicative of this condition. Frequently 
the condition of the bowels furnishes no information of the actual state of 
affairs. Recent researches tend to show that an excess of ethereal sul- 
phates in the urine (indican) in connection with other symptoms is a good 
index of auto-intoxication. 

When auto-intoxication is suspected as the causative factor in any 
nervous disorder, it is essential to regulate the diet in the manner 
already mentioned, and there are at our disposition a number of intes- 
tinal antiseptics which, though not always efficient, are yet often of 
very great benefit. I have found, in my own practice, that beta- 
naphtol is one of the best intestinal antiseptics. I give it in capsules 
of five grains each, two hours after eating, with water. In several cases 
of epilepsy and of melancholia it has acted exceedingly well. In many 
cases of epilepsy salicylate of soda has also proved itself of great value. 
Salol, too, is a good intestinal antiseptic. Sometimes I have made 
excellent use of peppermint for the same purpose. I think the abun- 
dant use of water a necessary adjunct in the treatment, usually advising 
the drinking of hot water several times daily on an empty stomach, and 
sometimes adding thereto frequent flushing of the large intestine with 
warm water. 

Electrotherapy. — General faradization with a current sufficiently 
strong to contract the muscles has much the same value as massage 
where the rest-cure is employed ; it exercises the muscles and stimulates 
metabolism. Over and above this it has a tonic effect. Galvanism is 
only of use in complicating conditions, such as neuralgias, sciatica, and 
the like. The same is true of the static and sinusoidal currents. 
Electrization of the head for the purpose of influencing illusions, hal- 
lucinations, and delusions is occasionally of service, but doubtless its 



GENERAL TREATMENT OF INSANITY 777 

influence is almost wholly of a suggestive nature. However, it is no 
to be interdicted on that account, for suggestion is in itself a valuable 
therapeutical adjunct, and so good a method of increasing its usefulness 
as is afforded by electricity is not to be slighted. Suggestion is a species 
of psychic therapy. 

Drugs. — The narcotics are of great importance in the treatment of 
insanity. Among these, opium and its alkaloids easily stand first. 

Opium, morphin, codein, all have a hypnotic effect, but their 
especial value lies in their sedative influence upon mental hyperesthesia, 
anxious states, etc.; in their contraction of the blood-vessels, and in 
their stimulation of the nutrition of the central nervous system. The 
hypodermatic use is best. They are particularly indicated in melan- 
cholia, acute alcoholic psychoses, and hallucinatory paranoia, very 
seldom in maniacal states. They are contraindicated in most maniacal 
conditions, collapse, fatty heart, uncompensated valvular disease, and 
marasmus. The patient should not know the name of the drug used. 
Opium and codein are preferable always to morphin, because of less 
danger of forming a habit. The doses must be gradually increased. 
The constipation at first present during the administration of opiates 
disappears later. 

Hyoscin, hyoscyamin, and duboisin are isomeric alkaloids, and 
nave much the same qualities and are alike in their effects upon the 
organism. Xext to the opiates they form the chief drugs of the 
alienist's armamentarium. Their great value lies in their sedative 
influence upon motor centers. They are used hypodermatically in doses 
of from yi-Q to -jig of a grain. Almost immediately after injection the 
muscles become incoordinated and weak, and in ten or fifteen minutes 
the patient sinks into a light slumber which lasts from six to eight 
hours. The peripheral arteries are contracted, giving the patient a 
striking pallor ; the breathing is slowed, the pulse retarded or made in- 
termittent, the throat rendered very dry, and the pupils enlarged and 
accommodation paralyzed. These drugs are contraindicated in heart 
disease, and in no case should they be continued any length of time- 
Precious as they are on the right occasion, their employment should be 
subject always to the careful and judicious supervision of the physician. 

Another feature of their physiological action to be borne in mind is 
their power to induce dreadful hallucinations in a well person — a fact 
which emphasizes the need of care in administering them to an indi- 
vidual whose mind is trembling in the balance. Long-continued use 
of these alkaloids interferes with nutrition. 

From what has been said of the action of these drugs, it will be seen 
that their effectiveness is most manifest in conditions of motor excite- 
ment, in mania, agitated melancholia (combined with morphin), in 
agitated dementia, and in the motor excitement of epilepsy or paresis. 
I have often been able to feed excited patients who refused food, imme- 
diately after the injection of the alkaloid, during the few minutes that 
elapse before the advent of sleep. 

The bromids, aside from their particular value in epileptic psy- 
choses, are often useful in other forms of mental disease, owing to their 



778 MENTAL DISEASES. 

effect in diminishing cerebral activity and reflex irritability. In epilep- 
tic insanities the combination of the bromids and opium is especially 
effective. They are of use in any mental excitement which is con- 
joined with some reflex irritability (illusions and organic sensations, 
uterine and genital disorders). As an anti-aphrodisiac they are employed 
in insanity with erotic manifestations. In large doses, sixty to ninety 
grains and over, they act well as a safe and innocuous hypnotic. 

Chloral hydrate is not so much used as formerly, though its hyp- 
notic effect resembles very closely natural sleep. It is applicable to 
acute hallucinatory conditions, insanities associated with chorea, and in 
the epileptic psychoses. In status epilepticus, per rectum it is one of 
the most valuable remedial agents. In some conditions, combinations 
of chloral with morphin are of much utility. Chloral is a heart poison, 
and its use is contraindicated in cardiac and vascular disease. Chloral- 
amid is of little value. 

Paraldehyd is a simple hypnotic whose utility is not sufficiently 
appreciated. Naturally, its bad taste and the rather disagreeable odor 
left upon the breath have limited its sphere of usefulness ; but it has 
no bad influence upon the heart or nutrition. It can be given in heart 
disease, and patients seem to thrive and grow fat upon it. The dose is 
from one-half to two drams, but increasing doses are necessary, and I 
have had patients who have taken four or more drams at a dose. It is 
especially useful in conditions of inanition and in insanities founded 
upon hysteria or neurasthenia, The taste and odor of the drug can be 
concealed in orange- water or weak brandy. Amylene hydrate is of less 
value ; it stands between chloral and paraldehyd. 

Veronal, trional, and sulphonal, as simple sleep-producing agents, 
are preeminent where nothing but sleep is the object to be attained. 
Trional and veronal act quickly, sulphonal slowly; hence a combination of 
two of them in equal doses is particularly fortunate in its results, inducing, 
as it does, rapid and prolonged slumber. Five to ten grains each, or more, 
if indicated, may be given at bedtime with a glass of hot milk. The 
tastelessness of these drugs affords the possibility of administering them 
without the knowledge of the patient, mixed with salt or sugar, or spread 
with butter upon bread. Sulphonal used for a long period produces mus- 
cular weakness and incoordination. All of these agents may, after a 
time, give rise to some disorder of the alimentary canal. They are said 
to occasionally increase the intensity of auditory hallucinations. 

Moral Treatment. — Psychotherapy is among the most important 
means of treatment of insanity. The general practitioner is especially 
concerned with it in the early stages of mental disorder ; later, if the 
patient is turned over to the care of the asylum, it is still of the utmost 
importance, and the physicians in institutions know well the necessity 
and utility of moral agencies in effecting a cure or in at least amelio- 
rating the condition of their charges. Physicians who have much to do 
with ordinary functional nervous disorders — hysteria, neurasthenia, mild 
depression, and hypochondriasis — are familiar with the wonderful influ- 
ence they are able to exert over the mental attitude of patients thus 
afflicted, by kindness, patience, firmness, interest, and sympathy. Every- 



GENERAL TREATMENT OF INSANITY. 779 

thing they say or do, if rightly said or done, conveys a suggestion, 
inspires hopefulness, increases the efficacy of their prescriptions, points 
out the way to health and a new lease of life. The insane also are in 
the same way dominated by the personality of the physician and of 
those chosen to carry out his instructions. Some physicians are fortu- 
nate enough to possess peculiar gifts in this way, and their influence is 
potent for incalculable good. Aside from this personal influence, the 
physician is called upon to direct and regulate the entire disposition of 
the time of the patient and to make for him the environment suitable to 
his malady. He prescribes isolation from friends, the care of strangers, 
the rest-cure, the periods and kinds of exercise, the mental and manual 
occupations, the amusements, all of which go to make up psychotherapy. 
Some of the principles of this moral treatment we will now briefly touch 
upon. 

The value of isolation in melancholia and of the rest-cure for both 
acute mania and melancholia has already been mentioned. There are 
cases of melancholia, however, in which a modified rest-cure is better 
than the complete rest-cure. In such cases, after recumbence in bed 
from six in the evening until noon the next day, much of the afternoon 
may be spent in simple exercise, such as walking slowly about out-of- 
doors. It is best not to seek, by amusements, visits of friends, and other 
cheerful devices, to raise the melancholiac from his depression, for usually 
these attempts rather add to his misery by force of contrast. A neutral 
atmosphere, so far as the emotions are concerned, is best, though an 
occasional word of confident reassurance is useful. 

In acute stages of insanity it is best not to discuss the hallucinations 
and delusions of the patient, although neither physician nor nurse 
should ever fall in with or act upon his erroneous ideas. Whenever 
good judgment suggests, a brief but positive denial of the truth of the 
imaginings of the patient should be made. Later on such correction 
may with advantage be made more frequently and constantly. 

When the patient is not taking a rest-cure, occupation of some kind 
is essential to his progress toward recovery. Most useful are all forms 
of muscular or manual employment, for labor of this kind keeps the 
attention more or less fixed upon what is being done, the flow of ideas 
is checked and limited to a considerable degree, and the mind is pre- 
vented from concentrating itself upon illusions, hallucinations, and 
delusions. Moreover, muscular exercise is an outlet for superfluous 
energy ; motor excitement is reduced by it ; tissue metabolism is accel- 
erated ; and when the work is over, the organism gains all the more 
readily a certain composure of mind and repose of body- Out-of-door 
occupation is best — garden and field work for men, garden work for 
women ; walking, bicycling, etc., for either sex. Among indoor em- 
ployments we have ordinary housework, drawing, knitting, sewing, 
embroidery, carpentry, wood-carving, etc., all of which employ the 
muscles methodically. In certain cases mental occupation is useful, 
though it should be of the simplest kind. For instance, during my 
practice at the Hudson River State Hospital for the Insane, we found 
much value in the establishment of a regular country school, attended 



780 MENTAL DISEASES. 

by patients of all ages. We bad " spelling bees," copying lessons, 
reading aloud, blackboard exercises, geography, simple arithmetic, sing- 
ing, and so on. * 

A very important point in the management of the insane is never to 
practise deception upon them in any way. Be absolutely truthful in 
every statement to them. Xever remove a patient to an asylum under 
the impression that it is a hotel or sanatorium. It is better to state 
exactly what is going to be done, and then use force in the removal, if 
necessary. 

Hypnotism has been frequently practised upon the insane, in the 
effort to modify hallucinations or delusions, rarely with any definite 
success, occasionally with ill results, and generally with no effect what- 
ever. 

There are a few conditions among the insane which require particular 
treatment or management. Among them are : 

Suicidal Tendencies. — Suicidal patients are among those who 
require constant watching and the removal of every means of self- 
injury. This is often difficult in treating such patients in their own 
homes. How difficult, it may be conjectured from the fact that, even in 
asylums, with all their safeguards, suicide is by no means infrequent. 
Thus, 145 patients in the asylums of the State of Xew York committed 
suicide between October 1, 1888, and September 30, 1906. 

Suicidal patients are to be watched night and day, and kept in bed, 
and even put in restraint, if desperate. I have known a patient to 
strangle herself with a cord while lying in bed under the eye of a 
nurse. Another, broke a small piece from a china plate and tried to cut 
her wrists under the bedclothes. While suicide is most common 
among melancholiacs, patients with general paresis, paranoia, epileptic 
psychoses, and toxic delirium sometimes attempt it. The physician 
attending such patients should see to the guarding of windows and the 
removal of keys, hooks, scissors, weapons, drugs, strings, long pins, 
matches — in fact, of all instruments and means which he may suspect 
to be utilizable for a suicidal purpose. 

Refusal of Food. — The acutely maniacal often can not be made to 
take sufficient nourishment, because they do not stop long enough in 
their ideomotor excitement to permit of eating. The watchful and per- 
severing nurse can generally, by persistent effort, induce the patient to 
swallow a considerable quantity of liquid food (preferably in a metal or 
heavy china cup, because the patient frequently knocks the vessel from 
the hand of the nurse). Such patients can often be fed, as already 
stated, immediately after a hypodermatic injection of hyoscin or duboi- 
sin before the supervention of sleep. 

Other patients refuse to eat because of delusions of poverty or 
poisoning, suicidal proclivity, or simply from absolute distaste. 

AVhere ordinary means fail, the nasal tube should be resorted to, — 
one of large caliber with rubber funnel attached, — and through this, 
once or twice daily, a mixture of a pint of milk, two or three raw eggs, 
a little meat-juice, and, if needed, brandy, may be introduced. 
1 See also Psychotherapy, page 771. 



MANIC-DEPRESSIVE INSANITY. 781 

Before resort to this means nutritive enemata may be employed 
(three raw eggs, a half-pint of milk, a half-pint of water, and a little 
meat-juice). 

I have been in the habit of delaying the use of the nasal or stomach- 
tube to the last moment of safety, even for several days, rather than 
subject the patient to the excitement of its employment. It is only in 
rare instances that feeding is not effected in some other way before the 
use of the tube becomes imperative. 

Violence and Destructiveness. — Hypodermatic medication and hot 
wet-packs are indicated in periods of excitement with tendency to vio- 
lence and destructiveness. It has already been intimated that active 
physical labor or exercise is a safety-valve for patients with proclivities 
of this kind. Isolation in an empty room with protected windows is 
sometimes resorted to in institutions, and abroad the padded room is a 
favorite place for patients whose violent jactitations may lead to serious 
injuries to himself. The padded room consists simply of a room lined 
as to walls and floor with cushions. Mechanical restraint is used in the 
last extremity, when chemical restraint and other means have failed. 
The camisole and safety-sheet are employed only in cases with desperate 
suicidal tendencies, proclivity to excessive masturbation, great violence 
and destructiveness, and where needed to keep in place surgical dress- 
ings, splints, etc. In asylums mechanical restraint has been nowadays 
almost entirely abandoned. 

Masturbation. — Masturbation is more often the consequence and 
concomitant of insanity than its cause. It may be ameliorated occa- 
sionally by drugs like bromids, camphor, and lupulin. Cold baths and 
hard physical labor are more successful in combating this habit. In 
excessive masturbation, constant watching day and night or the use of 
mechanical restraint is necessary. The use of blistering fluids on the 
genital organs is only of temporary service. There are instances in 
which the habit is so fixed and so uncontrollable — for example, among 
some imbeciles — that surgical interference would be quite justifiable 
(castration, clitoridectomy, ovariotomy, section of the pudic nerves, 
ligation of the vas deferens). 



CHAPTER VI. 
MANIC-DEPRESSIVE INSANITY. 

Manic-depressive insanity is best exemplified by cases of circular 
insanity in which we have recurring cycles of maniacal and melancholic 
outbreaks. But it is the merit of Kraepelin to have studied large 
numbers of patients suffering from mania or melancholia for periods of 
years, delving deeply into their previous histories, and following them 
up long after they had left his immediate professional care. This 
method of observation led to surprising results, not only in the matter 
of diagnosis, but also of prognosis. The profession had long fancied 
that little could be added to our clinical knowledge of the types of 



782 



MENTAL DISEASES. 



insanity however much remains to be learned as to their pathology. 
Certainly, very little brush-work was needed to complete the maniacal 
picture, and melancholia has been a classical syndrome since the time 
of Hippocrates. That these two contrasted phases of mental disorder 
sometimes appeared successively in the same individual, as an alternat- 
ing or circular insanity, was also well known, but such combined exam- 
ples were esteemed exceptional and rare. It was here that the astute 
German clinician stepped in and, by taking the long view over periods 
of years in his cases, made the discoveries which have rather upset our 
former classifications, and overturned some of our criteria for prognosis. 

He learned by his investigations that not only is alternating insanity 
much more common than psychiatrists deemed it to be, but that the 
majority of patients suffering from what we formerly looked upon as a 
pure mania or a plain melancholia proved by their previous or subse- 
quent histories to be subject to recurrences of attacks, which may be 
either maniacal or melancholic ; and, furthermore, that there are many 
patients who present on careful study simultaneous manifestations of 
both these phases — i. e., a mixture of manic and melancholic symptoms 
at one and the same time. 

For instance, the following table shows the contrast between the 
cardinal symptoms of mania and melancholia: 

Mania. Melancholia. 

Exaltation. Depression. 

Accelerated flow of ideas. Retarded flow of ideas. 

Motor excitement. Motor inhibition. 

Now we have occasionally cases of manic stupor (combination of 
exaltation and motor inhibition), or again agitated depression (combina- 
tion of motor excitement, accelerated flow of ideas and depression), or 
still further the so-called unproductive mania (combination of exaltation, 
motor excitement, and retarded flow of thought) . 

The term manic-depressive insanity is thus made to cover almost all 
of the old types of insanity that we formerly looked upon as separate, 
sharply -denned clinical syndromes, viz. : mania, melancholia, and cir- 
cular insanity. And Kraepelin naturally assumes for manic-depressive 
insanity an identical pathology for its contrasted or mixed manifesta- 
tations, though what such pathology may be is wholly a matter of specu- 
lation. Kraepelin limits the term melancholia to the depressed psychosis 
of senility. There is no doubt that we owe Kraepelin much for the 
new views thus given us. It may be, however, that modifications will 
be made as time goes on in this conception of the manic-depressive syn- 
drome. The brilliant exponent of manic-depressive insanity has the 
advantage of us at present in having already accumulated his material 
requiring decades of observation for verification, while we must wait 
years yet with our own cases before determining for ourselves the ulti- 
mate truth of his conclusions. Many of us doubtless have cases in mind 
which have passed through an attack of ordinary mania or melancholia 
with recovery, without history of previous attacks, and with no subse- 
quent attacks for years to the present time. We must now have the feel- 



MANIC-DEPRESSIVE INSANITY. 783 

ing that recurrence in one or the other phase is a possibility, and y et the 
patient may go through life without such recurrence. Under the cir- 
cumstances, is it worth while to change the name of the disorder from 
its well-known designation to the complex phrase manic-depressive 
insanity? And is it altogether profitable to exchange that classical 
immemorial expression "melancholia" for the cumbrous phrase, "the 
depressed type of manic-depressive insanity/' when we mean exactly 
what we did before, only assuming a new theory as to probable pathol- 
ogy? Why abandon the word " mania," when language needs conden- 
sation, for a phrase like "the manic type of manic-depressive insanity?" 
The clinical pictures remain the same ; their interrelations are differently 
conceived. Some of the features of these psychoses which led Kraepelin 
to classify them under the one head of manic-depressive insanity, and 
to assume them to be equivalents of one and the same fundamental 
pathological process, are as follows : 

The coexistence in the same subject of alternating mania and mel- 
ancholia (circular insanity). 

The presence in all forms, whether excited, depressed, or mixed, of 
certain fundamental symptoms, such as psychical inhibition (weakened 
attention, retarded flow of ideas, insufficient attention, indifference) and 
exalted mental automatism (flight of ideas, irritability, impulses, delu- 
sions, hallucinations and illusions, fixed ideas, obsessions). 

Classification of Manic-depressive Insanity. — Kraepelin divides 
the forms of psychoses under this heading as follows : 

1. The manic type of manic-depressive insanity. 

2. The depressed type of manic-depressive insanity. 

3. The mixed type of manic-depressive insanity. 

The manic type is separated into three forms: simple, delusional, 
and confusional. 

The depressed type is divided into three forms : simple, delusional, 
and stuporous. 

The mixed type is exemplified in cases of circular insanity, and also 
in very singular and varied mixtures of the two contrasting phases at 
the same time. Thus, some patients present a combination of psycho- 
motor excitement with emotional depression, and others psychomotor 
inhibition with emotional exaltation. Still another group of cases is 
characterized by a combination of stupor with motor excitement. 

A further classification of manic-depressive insanity, showing the 
various old forms included under this heading, is as follows : 

, -n . !• • •,• f Recurrent mania. 

1. Periodic insanities { Eecurrent me i ancho l ia . 

2. Alternating insanity, Circular insanity. 

3. Irregular forms. 

Etiology of Manic-depressive Insanity. — What has been said in 
the previous chapter as to etiology of insanity in general need not be 
repeated here. Kraepelin finds heredity a feature in about eighty per 
cent, of his cases of manic-depressive insanity. This psychosis forms 
about fifteen per cent, of all admissions to asylums. The disease gen- 



784 MENTAL DISEASES. 

erally begins before the twenty-fifth year, but a first attack may take 
place before the tenth year or not until after the fiftieth year of life. 

Prognosis. — The prognosis of recovery from the existing attack of 
mania and melancholia is favorable, from circular insanity, unfavorable. 
But from the new standpoint, given us by Kraepelin, we are not able 
to preclude a recurrence of attacks of mental disorder in a patient re- 
covering from mania or melancholia. While the prognosis, therefore, 
is favorable as regards the single attack, the possibility of subsequent 
attacks must be carried in mind by the physician in discussing the 
prognosis with the family. 

THE MANIC PHASE. 

As already indicated, the cardinal symptoms of the manic phase are 
the elated mood, flight of ideas, and motor agitation. An outbreak of 
mania is often preceded by a period of depression lasting from a few 
days to a few weeks, sometimes as long as two months. This prodromal 
stage is characterized by a general feeling of malaise, vague uneasiness, 
and hypochondriacal complaints, accompanied often by headaches, ceph- 
alic paresthesias, constipation, loss of appetite, sleeplessness, and some 
loss of flesh. 

When the true mental disorder begins to manifest itself, the sorrowful 
mood begins to give way to an exalted condition, which the patient 
looks upon as a state of renewed health and well-being. He takes a 
renewed interest in everything, and becomes unusually cheerful and 
talkative. The degree of increasing exaltation varies much in different 
cases. In mild cases the patient begins to surprise his intimates by his 
loquacity, facetious remarks, jocularity, and by his rather immoderate 
actions and undertakings. He enters upon many new schemes ; makes 
innumerable calls upon friends and acquaintances ; writes numberless 
letters ; purchases unnecessary articles ; and is inclined to excessive in- 
dulgence in tobacco, wine, and venery. There is considerable mobility 
or lability of the emotions, so that the elation may readily pass into 
conditions of anger or tears over trifles. In more severe types all of 
these symptoms are aggravated. A veritable chaos of ideas throngs 
through his mind, and the effects upon movement of this crowding series 
of ideas amount to a constant motor agitation. The patient laughs, 
declaims, sings, shouts, makes grimaces, dances, runs about, and becomes 
destructive and filthy, all inhibitory idea-associations ceasing to have 
any influence over the rioting torrent of thought. In still severer 
grades we have the picture of an acute delirium, boisterous incoherence, 
a motor agitation attaining to violent jactitation, and an actual and con- 
siderable increase of temperature. 

The patient with mania is fundamentally optimistic and egotistic. 
Everything about him is rose-colored. He feels rejuvenated; rejoices in 
his health, strength, and vitality ; is delighted with the vivacity of his 
ideas and the untrammeled virility of his intellectual processes. His 
general and special sensibilities are ordinarily unaffected ; in only about 
one-fifth of the cases are illusions and hallucinations present, and these 
are almost always limited to vision. Occasionally there are illusions 



MANIC-DEPRESSIVE INSANITY. 



785 



and hallucinations of taste and touch. Illusions of the special senses 
are more frequent than hallucinations. The manias of extreme youth 
or age are especially prone to manifest hallucinations. Mania marked 
by the presence of numerous illusions and hallucinations is often desig- 
nated as hallucinatory. 

The flight of ideas in mania is naturally most conspicuous in the 
speech of the patient, -which varies from garrulity to logorrhea. In 
the milder degrees of loquacity we are 
still able to follow the sequence of asso- 
ciations. The sentences are often bound 
together by the ordinary relationship and 
connections of ideas, but among which 
many latent ideas spring into conscious- 
ness and expression ; and, again, the 
sounds of words spoken suggest others 
of similar sound, giving rise to rhymes 
and assonances. Thus, the sight of 
the physician may suggest drugs, a cer- 
tain apothecary, in a special street, in 
some familiar town ; and the town may 
in turn give rise to another series. On 
the other hand, the physician's " How 
do you do?" may invoke a string of 
assonances (verbigeration) commingled 
with sentences expressing their associ- 
ated ideas — shoe, two, new, grew, blue, 







Fij 



-Manic phase. 



crew, etc. But in the 



more striking 



grades the logorrhea is so pronounced that it is impossible to find clues 
to any association, whether of sound or idea. It becomes a chaos of 
words, consequent upon an actual dissociation of the ideas in the rush- 
ing stream of thought — a secondary incoherence. The entire loss of 
inhibitory control of ideas is especially shown in the absolute lack of 
modesty, in the tendency to the employment of vulgar and obscene 
words and expressions. This profanity and obscenity become all the 
more astonishing by contrast, when it is observed, as it often is, even in 
the most refined and cultured of women. 

The attention of the patient with mania is extraordinarily increased, 
so that the most insignificant trifle in his environment does not escape 
him. But this very increase of the power of attention, combined as it 
is with an unpausing stream of ideas, entails an absolute lack of con- 
centration. His attention cannot be held a moment. It is constantly 
being drawn or distracted to every object or occurrence in his environ- 
ment and we speak of this symptom as distractibility. AVhen the ex- 
citement is intense and the distractibility high, there is often an appear- 
ance of clouding of consciousness and an apparent moderate disorienta- 
tion, especially apt to be shown in the misnaming of persons. The 
rapid sequence of ideas tends to give them all an equal value (a leveling 
of ideas). The patient's memory, too, seems preternaturally intense, 
and it is remarkable how, after recoverv, he may remember all the de- 

50 



786 MENTAL DISEASES. 

tails of his delirious activity with great distinctness. Indeed, the 
patient, in the midst of the chaotic turmoil of his mind, often recog- 
nizes, as if he stood apart from and judged himself, the very madness 
of his fancies and acts. The judgment-associations are, in fact, normal. 

The elated mood and rapid flow of ideas give rise to delusions of 
expansive character, mostly in regard to strength, beauty, and intel- 
lectual powers, but often also in relation to wealth, social position, etc. 
In severe cases there are the most marked delusions of grandeur, the 
patient affirming himself or herself to be a prince, president, king, 
queen, Christ, the bride of Christ, the mother of God, etc. A peculiarity 
of these affirmations is their transitory character, their impermanence. 
A patient will, in the same breath, call himself a millionaire, broker, 
and king, and in the next a minister of the gospel and railroad magnate. 
If sharply told by the physician to stop such nonsense, he will often 
say it was only a joke, or he had said such things for fun. This shows 
very well the latent consciousness of the patient of the true state of 
affairs. Occasionally, but rarely, the delusions take on a paranoid char- 
acter, and in a mild type of the disorder one might well confuse this 
phase with a genuine paranoid psychosis. When such a condition re- 
curs from time to time, it has been called paranoia periodica. 

The sexual instinct is morbidly exalted, giving rise in both sexes to 
immodesty and obscenity of speech and manner, and often to sexual 
excesses and masturbation. 

The actions of patients with mania correspond in character to the 
degree of acceleration in the stream of ideas. When this is very great, 
turbulence, violence, and destructiveness are common, not with any 
homicidal or suicidal intent, because they are incapable of acts requiring 
any particular concentration of mind or reflection, but simply as the 
result of uncontrollable automatic impulsions. 

Sleeplessness is characteristic of this condition. General sensibility 
appears to be benumbed, probably because of the want of concentration 
of thought. Patients seem insensible to changes of temperature and to 
severe pain. Such a state often masks the most serious disorders, like 
pneumonia or the pains of labor. I once made an autopsy upon 
a woman suffering from acute mania who died suddenly. She had been 
for days in the wildest uproar of mind and body. The cause of death 
was an acute peritonitis from rupture of a perforating duodenal ulcer. 
The peritonitis had evidently existed for several days, yet this painful 
affection had clearly had no effect upon the course of the mental and 
motor symptoms. 

Some cases of mild maniacal character exhibit a peculiar tendency to 
logically explain and excuse their insane acts, and this type is often 
designated as reasoning mania. 

As already stated, mania often begins with a prodromal stage of 
depression. After the exalted stage has culminated and at the beginning 
of convalescence, a reactive stage of depression is presented, character- 
ized by irritability, sensitiveness, and lacrymosity. This stage of de- 
pression may be so intense as to be an actual melancholic phase of 
simple nature or accompanied with stupor. In instances of this kind 



MANIC-DEPRESSIVE INSANITY. 737 

the possibility of the patient's having the circular form, instead of a 
simple manic state, is to be considered. 

Except in the severest type of mania (acute delirium) the bodily 
temperature runs a normal course, sometimes even showing a subnormal 
character. In acute delirium the temperature may reach 104° or 105° 
or more. The pulse is small and normal, or but slightly increased in 
frequency in mania. There are no paralyses, no true anesthesias. The 
absence of fatigue is often surprising. The deep reflexes are exagger- 
ated, as a rule. The salivary secretion is frequently increased. Per- 
spiration is diminished and sometimes transformed in character, so as to 
give a peculiar and often extremely disagreeable odor (kakidrosis). 
Gastric disorders are nearly always manifested, and the tongue is heavily 
furred, frequently dry. In severe cases albuminuria, propeptonuria, 
and hyalin cylinders are frequently found. The general bodily weight 
diminishes during the progress of the disease, but rapidly increases with 
convalescence. There is a corresponding condition of the appetite, an 
anorexia during the early stage and until the culmination ; then an in- 
crease of appetite amounting often to bulimia. The face is sometimes 
slightly suffused, but, as a rule, marked by a yellowish pallor. As the 
patient emaciates this becomes more noteworthy, and at the same time the 
features become pinched and sharp and the eyeballs sunken. This outline 
and color of the face, with a tendency to dryness of the lips and a heavily 
furred and dry tongue, are indications of the progress of exhaustion. 

Varieties. — According to the intensity of the manifestations, upon 
the basis of the course of the disease, from the nature of certain con- 
comitant symptoms, and, fourthly, in relation to some of the etiological 
factors, the manic phase is frequently divided into several varieties bear- 
ing some special qualification. Mania mitts is the mildest form of the 
psychosis. Hypomania designates also a mild type, and the so-called 
reasoning mania is always of a hypomanic nature. Acute delirious 
mania, a very rare disorder, is possibly sometimes a most aggravated 
condition of the manic phase of manic-depressive insanity, but doubt- 
less more often the result of some acute infection or intoxication due to 
actual unrecognized physical disease. The term transitory mania was 
formerly employed to describe a delirious condition of very brief dura- 
tion, a few hours or a day or two, but these cases do not really present 
the characteristic symptoms of a true mania. Periodic mania is a form 
in which attacks of mania follow one another with perfectly normal but 
generally irregular intervals of days, months, weeks, or years. The 
attacks themselves last from a few days to a few months. Usually the 
prodromal depressive stage is absent, the culmination rapid, and conva- 
lescence seldom marked by the interesting depressive affects of ordinary 
mania. The periodic attacks are very apt to be distinguished by the 
presence of special symptoms, such as a reasoning tendency, tendencies 
to impulsive acts, arson, stealing, assaults, sexual and alcoholic excesses, 
and to severe headaches. The longer periodic mania endures, the less 
distinct become the normal features of the intervals. Recurrent mania 
and intermittent mania are only other names for periodic mania. Various 
etiological factors have in times past given rise to such designations as 
epileptic, alcoholic, morphin, puerperal, senile mania, etc., in some of 



788 



MENTAL DISEASES. 




Fig. 304.— Manic phase of long duration. 



which the maniacal excitement takes a special color from its oause. 
Thus, the toxic deliria are generally acute hallucinatory conditions. 

Course of the Disease. — Re- 
covery takes place in some seventy 
per cent, of cases. Sometimes it is 
exceedingly rapid, but usually the 
progress is gradual and rhythmical 
to the normal state. This rhythm 
is a sort of oscillation between good 
and bad days, but with constant 
improvement. Occasionally the 
patient improves steadily and un- 
interruptedly until recovered. Re- 
covery is sometimes not perfect, so 
that we speak of it as recovery 
with defect. 

Death takes place in but five per 
cent, of cases. The cause of death 
is sometimes exhaustion, as in acute 
delirium ; more often an intercurrent 
affection, such as pneumonia, neph- 
ritis, and the like. Heart disease 
and alcoholism add greatly to the 
danger of lethal termination. 

Diagnosis. — One must be care- 
ful not to confound delirium from fever with an attack of acute mania. 
Except in acute delirious mania, the absence of fever in the mental dis- 
order should be distinctive. The three cardinal symptoms of mania 
should be kept constantly in mind — viz., the exalted mood, the acceler- 
ated flow of ideas, and the motor excitement. We must determine 
whether the syndrome is complicated by other conditions, such as gen- 
eral paralysis and alcoholism. A very mild degree of mania may pass 
unrecognized, unless it is possible to diagnose it from a pronounced 
change in the character of the individual and from the accompanying 
insomnia. The physical symptoms and the defect of intellect should 
suffice to distinguish the exalted stage of general paresis from an acute 
mania. The delusions, too, of paresis have a peculiar monstrosity of 
character that differentiates them from the exalted ideas of the maniac. 
Sometimes, however, there will be difficulty in making a speedy diag- 
nosis between these two analogous exalted conditions. 

The manic phase must be differentiated from conditions of excite- 
ment often found in dementia prsecox. If the characteristic deteriora- 
tion of the latter disorder is not observed, long observation only can 
insure the correct diagnosis. 

Treatment. — What has already been said in the chapter on General 
Treatment is applicable here. The requisite isolation and supervision 
of a patient with acute mania can seldom be satisfactorily accomplished 
outside of an asylum, unless his means are sufficient to secure the needed 
nurses and suitable surroundings. 



MANIC-DEPRESSIVE INSANITY. 



789 



Rest in bed aids in the prevention of exhaustion, and renders super- 
vision, care, and feeding more easy. To induce sleep and allay motor 
excitement, hydrotherapy and the hypodermatic use of hyoscin, hyoscy- 
amin, or duboisin are extremely valuable. In mild cases equal parts 
of trional and sulphonal are preferable to the drugs just mentioned. 
Paraldehyd is also an excellent hypnotic for mild cases. 

Overfeeding is also an extremely important indication. Liquid and 
easily digested foods are to be recommended. The bowels should 
always be regulated. Brandy is added to the liquid food when ex- 
haustion is imminent, but otherwise stimulants are contraindicated. 
Should there be danger of collapse, the repeated hypodermatic injections 
of ordinary salt and water (ten to fourteen ounces) over the abdomen 
or in the thigh are valuable. In the depressed period of convalescence 
small doses of opium are often useful. 

THE DEPRESSIVE PHASE. 

The cardinal symptoms of the depressive phase of manic-depressive 
insanity are, as stated above, a depressed mood, retarded flow of thought, 
and motor inhibition. 

The affective state in this psychosis varies from simple dejection, in 
which every thought and everything in the environment of the patient 
has a sorrowful color, to a state of profound depression, in which the 
patient is either paralyzed by the dreadful nature of his concepts or 
thrown into a state of agitated suffering associated with marked pre- 
cordial distress. There are many degrees lying between these extremes. 
This morbid depression is in many ways paralleled by and analogous to 
the conditions of normal grief in which we observe a varied behavior of 
different individuals under the influence of distressing emotions ; some 
become strangely quiet and still ; others, again, make noisy and agitated 
demonstrations of their grief. Normal grief, 
too, is often accompanied by sensations of 
choking and of sinking at the heart, which 
are similar but comparatively mild manifes- 
tations of the precordial anxiety and dread 
of the psychosis. AYe observe often in 
melancholia a rhythmic oscillation of the 
state of depression during the day, and fre- 
quently from one day to another. Thus, 
the depression is at its height in the morn- 
ing (when suicidal tendencies not infre- 
quently present themselves), being followed 
by a recession with another exacerbation 
toward night. Very often patients sleep 
better on alternate nights, and manifest 
intenser emotional depression on alternate 
days. In some cases, presenting what is 
known as the apathetic form of melancholia, the patients complain that 
they have no feeling at all ; that they are affected neither by things 
cheerful nor grievous, pleasant nor painful ; that they have no longer 
any love for family or home, or interest in anything ; that they can 




Fig. 30.").— Depressive phase. 



790 MENTAL DISEASES. 

never be sad or glad again. Sensory disturbances are often absent. In 
the apathetic variety there may be analgesia. Marked illusions and hal- 
lucinations are observed in only about a tenth of all cases of melancholia. 
The paresthesias in the region of distribution of the vagus are neither 
illusions nor hallucinations, but they may give rise to delusions ; they 
depend probably upon vasomotor disturbances. The melancholiac per- 
ceives and identifies ordinary and special sensations slowly and with 
difficulty. The peripheral stimuli of his environment go unnoticed. 
When hallucinations are present, they usually affect most of the senses, 
and are terrifying and dreadful in character. The patient sees the 
flames of hell, phantoms and ghosts of dead persons ; hears voices 
which reproach and threaten him, or the sounds of machinery and other 
tortures which are being prepared to cut him up or mutilate him ; 
smells and tastes horrible things, and so on. 

Next to the effect of depression, the most noteworthy symptom of 
melancholia is the slowing of the thought processes. Sometimes the 
retardation is altogether out of proportion to the depression, the retarda- 
tion being great and the depression very mild. 

The processes of memory are retarded, and the attention of the patient 
difficult to gain. A minute or several minutes are required for the answer 
to the simplest question. Sometimes no answer is given at all, or at most 
the lips stir inaudibly. 

The contents of the concepts may, in milder degrees, show no de- 
lusions. More often the patient attempts to explain his feeling of 
abject misery and distress either by the presence of some fancied physi- 
cal ailment (hypochondriacal melancholia, with delusions of having 
syphilis, consumption, cancer, impotence, incurable disorders of the 
stomach, bowels, etc.), or as the result of some sin of his past life. To 
the delusion of having sinned an especial color is given by the character 
of the patient's early education. Thus, a strong religious bias gives rise 
to delusions of having committed the unpardonable sin, of being doomed 
to hell, to everlasting punishment, to be buried alive, etc. Often such 
delusions are connected with some trivial error of his past life. For 
instance, a patient of mine recently told me, " I once chloroformed a 
dog to death and buried him. I think now I made a mistake in not 
making positively sure that the dog was dead, and as a result I am 
doomed to be buried alive also, and to be tortured with dreadful 
thoughts through eternity, each day the torture growing more dreadful, 
up to the decillionth power of intensity." 

Patients often say they are not sick, they are only wicked. They 
have committed sins not only against God, but against society. Not 
only must they undergc the punishment ordained by Heaven, but they 
must answer to man for infringements of human law. They are to be 
put in prison, to be killed, to be hung. Thus they come to delusions 
which are somewhat similar to persecutory ideas in that they believe the 
officers of the law are after them, etc. These differ, however, from the 
true persecutory delusions in winch patients have no self-depreciatory 
ideas, but believe themselves to be the innocent victims of inimical con- 
spiracies. Delusions of poverty are very common, but more especially 
in involution melancholia, to be described later on. 



MANIC-DEPRESSIVE INSANITY. 



791 



The conduct of the melancholiac depends upon the contents of his 
consciousness. In his expression we note the lines of extreme depres- 
sion, or of fear and terror. The patient with the delusion of sin or 
poverty, for example, presents motor inhibition. He sits in one place 
with head bowed down, unmindful of what goes on about him, indiffer- 
ent or apathetic to all questions put to him, resisting every attempt to 
give him food or medicine, or to dress and undress him, or to give him 
exercise. He is lost in the contemplation of his misery. Another 
patient, with these or similar depressed ideas more accentuated, or with 
marked hallucinations, will wring his hands, tear his hair, walk or run 
up and down, bewailing his misfortunes, or seeking to escape the 
dreadful fate in store for him. In the first case the motor inhibition 
may be so complete as to make the patient perfectly immobile, so that 
not a single voluntary movement is made ; even micturition and defeca- 
tion are involuntary. Suicidal tendencies are observed in every type 
of melancholia, but especially in those with precordial distress and agi- 
tation. In the milder degrees, an attempt at suicide is often the first 
intimation to friends of the actual existence of insanity, since in these 
cases, outside of the sorrowful mood of the patient, the intellectual proc- 
esses may go on as before. Cases of melancholia attonita (with marked 
motor inhibition) also often make attempts at suicide, unexpected explo- 
sive attempts, the result of the sudden letting up of mental and bodily 
tension. This has been called the raptus melancholicus. Homicidal 
attempts and violent assaults are occasional in melancholia. A melan- 
choly mother kills her children to put them out of an unhappy world ; 
or a sudden dangerous assault is made as an explosion of motor tension. 
Hypochondriacal melancholiacs may mutilate themselves. Patients with 
melancholia have also been known to enter upon alcoholic excesses to 
drown their misery. The refusal of food is almost the rule of conduct 
in all forms of melancholia. Sometimes this refusal rests upon a delu- 
sional foundation : the patient thinks he can- 
not digest his food, that it never passes 
through him, that he is too poor to pay for 
it, that he is too wicked to eat, that he must 
do penance, and so on. Or he refuses food 
with deliberate suicidal intent. Generally, 
profound anorexia, constipation, and gastro- 
intestinal disorders are at the basis of this 
refusal to eat. 

The pulse is usually subnormal in fre- 
quency, though sometimes, especially in agi- 
tated forms, accelerated. The peripheral 
arteries are contracted and the extremities 
cold. The respiration is retarded and super- 
ficial, as a rule, though it may be increased 
in the agitated types. Sleep is much disor- 
dered, and even altogether absent, in severe 
cases. The patient emaciates both through refusal of food and because 
of disordered digestion. The gastric juice and saliva are often dimin- 
ished in quantity. The tongue is foul and furred, and obstinate consti- 




Fig. 306.— Depressive phase. 



792 MENTAL DISEASES. 

pation is present. As a result of constipation, elevations of temperature 
may be observed, but otherwise the temperature is undisturbed. The 
surface temperature in the extremities is often much reduced. Amen- 
orrhea is frequently induced by the depressive as well as the manic 
phase. 

Varieties. — The depressive phase may show itself as follows : 

1. Mild depression, with very light retardation. 

2. Strong depression, with very light retardation. 

3. Depression with the development of delusions of a depressed 
nature, and various grades of retardation. While the delusions are 
usually melancholic, they may also be paranoid or hypochondriacal in 
character. 

4. Complete retardation, with the facial expression of depression 
(depressive stupor). 

5. Periodic, recurrent, or intermittent types. These designations 
have the same significance as in mania, attacks of the depressive phase 
occurring at intervals throughout the life of the patient. 

Course of the Disease. — There is no such distinct prodromal stage 
in this phase as in the manic. The period of invasion is deliberate, and 
the symptoms chiefly manifested at first are gastro-intestinal disorders, 
dyspepsia, loss of appetite, constipation, accompanied by sensations of 
pressure in the head or headache, insomnia, and general malaise. The 
depression itself is the cardinal early psychic symptom. This phase, 
like all psychic disorders, is slow in its progress, and runs a course of 
from three to six months in the most favorable cases, but sometimes a 
year or two or three elapse before recovery takes place. Ordinarily, 
recovery is gradual, and is frequently accompanied by a species of 
reactive exaltation. Occasionally recovery is quite rapid. In women 
the approach of convalescence is indicated by a return of the menstrual 
function. In all cases improvement in physical health accompanies 
convalescence. 

Kecovery from the attacks takes place, according to various authori- 
ties, in between 70 and 90 per cent, of the cases, but of course the ten- 
dency to recurrence in the same or opposite form in all these cases must 
always be kept in mind. 

Death in cases of melancholia is due to suicide, marasmus, visceral 
disorders, diarrhea, pneumonia, etc. A very large number of long- 
standing cases die of tuberculosis. 

Diagnosis. — One of the most common conditions with which melan- 
cholia may be confounded is a depressed stage of general paresis. The 
chief points of distinction are the actual intellectual defect nearly 
always demonstrable in paralytic dementia, and especially the physical 
symptoms of paresis, pupillary changes, faciolingual tremor, character- 
istic speech, greatly exaggerated or lost deep reflexes, and one-sided 
facial weakness. The depression of the paralytic dement is superficial. 
His melancholy delusions are ordinarily distinguished by their inordinate 
and preposterous character, by the monstrosity of their contents. In 
addition to these points, the signs of previous syphilis and the age from 
thirty-five to fifty years would have some corroborative value in the 
diagnosis of general paresis. 



MANIC-DEPRESSIVE INSANITY. 793 

The stupor of one form of dementia pnecox must de differentiated 
from that of the melancholic phase. In the former we have, with the 
stupor, often tension and negativism, and the face is either expressionless 
or grimacing. In melancholic stupor the facial expression tends to 
show depression or suffering. 

There are instances of such a disorder as typhoid fever being tem- 
porarily mistaken for melancholia, but naturally the course of the tem- 
perature and the character of the stupor or delirium would soon correct 
such an error. 

Treatment. — The first consideration in the treatment of acute 
melancholia is isolation. Separation from the friends and relatives and 
removal from the environment in which the psychosis has developed are 
of the greatest importance. "With familiar faces and objects about him, 
and with his kin offering their help and sympathies, the keenest realiza- 
tion of his condition is brought home to the melancholiac. He feels 
among them all the more deeply a sense of his incapacity, of his 
inability to fulfil the ordinary duties and demands of his usual daily life. 
Whether the patient is to be isolated by commitment to an asylum 
depends upon several circumstances : his means ; the intensity of his 
malady ; the presence of suicidal tendencies. There are very mild cases 
in which moderate travel, a sojourn in the country with a nurse, a few 
months at the house of some country physician or in a small private 
asylum, will result in recovery. But the responsibility for such a 
course must rest with the physician who advises it, and he must keep in 
mind the danger of suicide in even the mildest type of melancholia. 
Not a few lives have been needlessly sacrificed by the inexpertness of 
the consulting physician. Besides extreme watchfulness on the part of 
the caretaker, who is not to leave the patient alone either night or day y 
a modified or a complete rest-cure is to be undertaken. For mild 
degrees of melancholia rest in bed from 6 p. m. until noon of the next 
day, with plenty of out-of-door exercise during the remainder of the after- 
noon, is most commendable. For the more severe types, continual rest 
in bed is requisite. The food should naturally be easily digestible 
and assimilable, and the patient should be made to take considerable 
quantities of milk and milk products (koumiss, matzoon, somal, etc.), 
raw eggs, meat-juices, and stimulants, when these are indicated. 
Massage and general faradization (sufficiently strong to contract the 
muscles) are useful to take the place of exercise in cases taking the 
complete rest-cure. Constipation should be regularly counteracted by 
abdominal massage, frequent purgation, glycerin injections, enemata, 
etc. This is particularly necessary in cases suspected of suffering from 
auto-intoxication. In these cases, too, gastro-intestinal antiseptics — such 
as salol, gr. v, or beta-naphtol, gr. v — should be administered thrice 
daily two hours after eating. Twenty grains of glycerophosphate of 
soda in a large glass of hot water a half hour before eating is also a 
useful remedial agent in melancholia. For sleeplessness the prolonged 
warm bath or the hot wet-pack is to be recommended ; in the event of 
their failure to induce a few hours' sleep in each twenty-four hours, 
sleep-producing drugs are necessary. Sulphonal and trional, of each 



794 MENTAL DISEASES. 

five to seven grains, given together at bedtime with a glass of hot 
milk or a cup of hot soup, are efficient in mild cases. 

The opium treatment is a sort of specific for melancholia, especially 
when there are agitation and precordial anxiety and distress. Beginning 
with a medium dose three or four times a day, we gradually increase it as 
required. Laudanum — the solid extract — or codein may be administered 
by mouth. When employed hypodermatically, which is usually best, the 
watery extract of opium is used. It is preferable to administer 
morphin only in the most aggravated cases, and in these it may often 
be advantageously combined with hyoscin, hyoscyamin, or duboisin. 
It is needless to say that the opium treatment should not be made known 
to the patient, and it is carried out with more safety, as regards the forma- 
tion of a habit, when the patient is in an institution. As the patient 
improves, the opium is gradually reduced until it can be finally cut off 
altogether. Opium does not increase constipation, except possibly for a 
few days when first employed ; it seems actually in many cases to 
diminish it. Sometimes, indeed, we need to treat diarrheas that arise as 
a result of the opium treatment. 

As soon as it becomes possible to do so, physical occupation should 
be begun and encouraged. A life out-of-doors, made interesting by 
different kinds of amusement or labor ; walks, field studies in natural 
history (botany, ornithology, geology, physical geography, etc.), golf, 
bicycling, agriculture, and gardening — all of these have their place 
among the remedial agents at the disposition of the discerning and judi- 
cious physician. 

THE CIRCULAR OR ALTERNATING TYPE, 

This form, now included generally under the designation manic- 
depressive insanity, has for decades been recognized as a special type 
of disorder characterized by the periodic alternation of states of melan- 
cholic depression and maniacal excitement. Among its well-known 
names are alternating insanity, insanity of double form, insanity of 
double phase, circular insanity, and cyclic psychosis. It is the perfect 
type to which the term manic-depressive insanity can be given without 
question or argument. There has been criticism of the inclusion of the 
old syndromes of simple and recurrent forms of melancholia and mania, 
just described under so comprehensive and general a head. The criti- 
cisms have been based upon the following : 

Kraepelin and his followers are chiefly familiar only with the severer 
types of psychoses met with in asylums. They seldom come in contact 
with the numerous mild cases of mania and melancholia observed by the 
specialists outside of institutions, where single attacks of one or the other 
disorder may occur but once in a lifetime. 

Even his adherents see many patients with recurrent melancholic 
attacks only, and without manic phases or symptoms, and vice versa. 

The symptoms of mania and melancholia, being so directly opposite 
in character, would rather argue a possibly different seat of the disorder 
in the brain, and a possibly different pathological cause. Since we know 
nothing whatever either of seat or cause, it is rather wild speculation to 
assume the same pathology. 



MANIC-DEPRESSIVE INSANITY. 



795 



If Kraepeliu had been content with enlarging the domain of circular 
insanity by the inclusion in it of his mixed cases and all of the recurrent 
types of mania and melancholia that show a tendency to alternation of 
phase, criticism would haye been less. 

It at least has simplified diagnosis to include every possible maniacal 
or depressed psychosis under the one term, and it was a rather singular 
hesitancy to exclude inyolution melancholia (all the symptoms of which 
are often met with in younger individuals without involution) for so 
long a time ; but the need of consistency seems to require including 
that under the general head at last. 

Probably there will be no more classification upheavals until we are 
able to classify de sedibus et causis morborum. 

Etiology of the Circular Type. — Heredity plays an especially sig- 
nificant part in the causation of circular insanity (60 per cent.). Not 





4*?' 


|% 




+ 


«ft 






■ «. 












^KpTV^ ■ 




Figs. 307, 308.*- -A case of circular insanity, photographed first in maniacal or exalted phase, and 
some months later in the melancholic phase (Dr. At wood). 



only do we find in the family history of the majority of these cases 
hereditary equivalents of different kinds, but direct inheritance of this 
particular variety of mental disorder is strikingly frequent. 

Many degenerates exhibit a tendency to an alternating variation of 
mood. Sometimes they are depressed and sometimes cheerful. It is 
probable that this oscillation of moods in an individual with strong 
hereditary taint may be the rudimentary foundation upon which the 
superstructure of a circular insanity is subsequently laid. 

Symptomatology. — The symptoms will vary at any given time 
according to the phase which the disorder has reached at the time of 
examination — the phase of depression or the phase of exaltation. The 
melancholic period may present any one of the forms just described, from 



796 



MENTAL DISEASES. 



a simple depressed condition, scarcely distinguishable from the 'normal 
state of the patient, to the most pronounced melancholic syndrome. In 
some cases we have melancholia simplex, in some agitation, in others 
stupor. When, in any given case, the melancholic phase recurs again, 
it is prone to wear the same features as in the first attack. Thus, mild 
depression or simple melancholia, melancholia agitata, or stupor may 
reappear again and again as the cycle returns, with the same phase and 
character over and over again. While this is true in the majority of 
cases of circular insanity, it is not always so, for occasionally the recur- 
ring depression changes its type in the various sequences. As intimated 
in the pages on the depressive phase, there is often a species of reactive 
exaltation in the convalescent stage of the disease, and occasionally this 
reaction becomes so accentuated as to develop a maniacal condition, so 
that we have presented to us a picture very like that of an alternating 
insanity. 



MentalSfote 



y4eute 
DelmousMtoia- 



'atliCL 



d imple 
£xaltatio/t- 






jleute 
Jl/felanckolicu 



or ^ttomtcu 



Ja> 



M 



June 



July Auy- 



Oct. 



Mi 



Dee 



Fig. 309.— Scheme of course of disease in periodical circular insanity. 



Like the melancholic phase, the maniacal period of circular insanity 
may vary in character from a condition of mild exhilaration and exalta- 
tion to the severest types of maniacal excitement and incoherence. As 
in the depressed period, there is the same tendency of the maniacal 
phase in its recurrences to present regularly the identical features of 
former attacks, though there are also exceptional instances here where 
subsequent outbreaks wear a different maniacal aspect. 

In the article on the manic phase mention is made of the fact that 
the convalescence from that psychosis is not infrequently characterized 
by a reactive depression, a lacrymose irritability. In some instances 
this may attain to the degree of a true melancholia, and thus place 
before us a cycle similar to that of an alternating insanity. 

Ordinarily we recognize two degrees of intensity in circular insanity — 
one in which both the mania and melancholia are mild, and one in which 
both phases are severe. But there are mixed types, in which the mania 
may be mild and the melancholia severe, or vice versa. 



MANIC-DEPRESSIVE INSANITY. 797 

Mild types of circular insanity — instances in which both the depressed 
and exalted phases are so moderate in degree as not to permit of com- 
mitment to an asylum — are not infrequently met with by the practi- 
tioner, and they are often difficult cases to handle properly. Thus, I 
have in mind two brothers, now over fifty years of age, who are both 
afflicted with circular insanity, manifested in a form very distressing to 
the relatives. A description of one will describe the other, and not 
only him, but many other similar cases : 

E., male, aged fifty-four, single, with hereditary taint, has for many 
years been subject to alternating attacks of depression and exaltation. 
I have seen and examined him in both phases. There is little, if any, 
discernible interval, but a gradual merging of one phase into the other. 
The depressed period lasts for from three to six months. In this, hi9 
expression is dejected ; he feels that life is a failure, that he can not live 
long. He consults various physicians for different maladies which he 
thinks may account for his general malaise. He can not concentrate 
his mind on anything, can not read or write letters ; refuses to transact 
the most necessary business in connection with his estate. He talks 
little, and broods over the mistakes and follies committed in the exalted 
phase of his disorder. He is rather suspicious and distrustful of his 
family. Sometimes he is inclined to put an end to his misery by suicide. 
Little by little this weight of depression begins to lighten, and he passes 
insensibly into a condition in which he begins to feel himself rejuvenat- 
ing. Life takes on a little rosier color; his malaise vanishes, and a 
sense of well-being begins to infuse itself through his body. His ex- 
pression changes from the fixed look of deep dejection to one of cheer- 
ful variability. In the place of quiet brooding we note an awakening 
interest in things about him. He begins to talk vivaciously, to be 
facetious and jolly, to write letters to his friends, to make frequent 
social calls, to take up the threads of affairs. He discards the doctors, 
for his health and strength were never better. He takes up some of 
his old hobbies, one of which is the collection of antiques, arms, plate, 
furniture, pictures, and specimens of ceramic art. He spends money 
freely, rather too lavishly. His collections are gathered together in 
storage warehouses, clubs, his own home, and the houses of his friends. 
He becomes extravagant and wasteful ; enters on great schemes of 
money- making, in which he becomes interminably entangled and 
meets with financial losses. His friends expostulate, and he becomes 
irritable and angry. He leaves them, to live in hotels. He buys a 
pair of fast horses and takes a drive of several weeks all over the 
country for hundreds of miles around. He grows boisterous in his con- 
versation, neglectful of the ordinary courtesies and civilities of social 
life, is lavish in his invitations, becomes a little excessive in drinking, 
is restless both night and day, travels from one city to another on the 
most trivial and eccentric errands. He sleeps little. Endeavors on 
the part of relatives to check the anarchy of his conduct bring from 
him threats of suits and of personal violence, and letters which are 
quarrelsome, offensive, even profane. With all this, there is no intel- 
lectual defect. He never has actually attempted any overt act which 



798 MENTAL DISEASES. 

would put him under the control of the law, or aid in his commitment 
to an asylum to save the dissipation of his energies and the waste of 
his property. Any jury would discharge him, for his conversation 
would show good memory, active intelligence, keen-witted replies to 
all questions. Step by step this stage of exaltation begins to pass 
away. He sinks nearer to his normal level, resumes a more natural 
conduct toward his family and friends, until again the depressive ele- 
ments reappear in his mental condition. Each stadium lasts for from 
three to six months, so that the cycle fills about one year. 

Varieties. — There are two main varieties of circular insanity. One 
is a true circular insanity in which the phases follow each other in a 
perfect cycle thus : mania, melancholia, mania, melancholia, mania, 
melancholia, and so on. The other type is one in which there is a 
certain periodicity of the maniomelancholic attacks as follows : mania, 
melancholia, interval, mania, melancholia, interval, mania, melancholia, 
interval, etc. Most cases can be catalogued under one of these two 
headings, but there are deviations which do not exactly conform to these 
well-defined types, and some authors have attempted to make further, 
but it seems to me unnecessary, subdivisions, upon the basis of varia- 
tions in the length of interval and irregularities in the sequence of the 
phases. Thus, some authors divide the varieties as follows : 

1. Circular insanity, with the following sequence : Mania, melancho- 

lia, mania, melancholia, etc. 

2. Alternating insanity, with this sequence : Mania, interval, melan- 

cholia, interval, mania, interval, etc. 

3. Insanity of double form, with either of these two sequences : 

Mania, melancholia, interval, etc. ; melancholia, mania, inter- 
val, etc. 

4. Alternating insanity of double phase, with the following sequence : 

Mania, interval, mania, interval, melancholia, interval, melan- 
cholia, etc. 

Course of the Disease. — In some patients circular insanity has 
its inception in the melancholic period, and in others it begins with 
the maniacal phase. Usually the initial stadium is melancholia. The 
transition from the depressed to the excited phase and vice versa is 
sometimes astonishingly sudden. The period of transformation may 
occupy but an hour or even less. In most cases the merging of one 
period into the other is very gradual. Another and extremely rare 
mode of transition is by successive alternations of depression and exalta- 
tion, an oscillating or rhythmic transformation. Still another method 
of change is by means of a lucid interval, brief or long, between the 
alternating phases, thus : mania, interval, melancholia, interval, mania, 
interval, melancholia, interval, etc. 

There is extreme variability in the duration of the maniomelan- 
cholic cycles. Sometimes they exhibit great irregularity of interval, 
from a few days to a year or more. Sometimes the maniacal phase 
lasts one day and the melancholic one day, so that the cycle is com- 
pleted in two days. In other cases, again, the cycle is completed in two 
weeks, or a month, or a year. Where alternation is completed in short 



MANIC-DEPRESSIVE INSANITY. 



799 



periods, there is a tendency to great regularity. Usually the melancholy 
phase lasts longer than the maniacal. 

Treatment. — All cases of circular insanity are best treated in an 
asylum in order to prevent suicide in the melancholic phase, and vio- 
lence, excesses, and riotous extravagance in the maniacal period. Un- 
fortunately, it is not always possible to protect the patient by this 
means, since juries are prone to allow every man his freedom, no mat- 
ter how dangerous to himself or others, so long as he does not behave 
as a raving maniac before them. Even in the intervals of lucidity it is 
better for the patient to be under medical supervision in some institu- 
tion, with the hope that the disorder may be arrested and future cycles 
prevented or postponed by the treatment. This treatment is based 
upon the principles described in the chapter on Treatment and in the 
pages on the manic and depressed phases in this chapter. 



Mental State 



4cute 
~DelLriousyuan.icL. 



JeuteM 



ania. 



Simple 
Sxaltcitton. 
1* 



Simple^bepremon 



Jleute- 
Mdane/ioticL 






Ja 



Feb. 



Mek 



ApL 



JlL 



July 



Aug. 



Sept. 



Oet Nov. 



Dee. 



Fig. 310.— Scheme of course of disease in continuous circular insanity. 



The rest-cure and hydrotherapy are recommended for both phases 
of the cycle. Hyoscin, hyoscyamin, and duboisin (gr. y^ to gr. -^) 
are useful in the excited stage, and the opium treatment in the depressed 
stage. 

INVOLUTION MELANCHOLIA. 

The term involution melancholia has been employed for the depressed 
psychosis that usually begins in women at the climacteric, between the 
fortieth and fifty-fifth years, and in men after the fiftieth year. The 
Munich school until recently made this form a clinical entity, distinct 
from manic-depressive insanity, and excluded it, together with certain 
other rather ill-defined depressed states called symptomatic depressions, 
from the larger category. But in 1907 Dreyfus published his investi- 
gation of the histories of eighty-one cases of involution melancholia 
from the material of the Heidelberg asylum, and concluded that nearly 
all were actually cases of manic-depressive insanity, since the funda- 



gOO MENTAL DISEASES. 

mental symptoms of this latter disorder were present in the great ma- 
jority. The conclusions he drew have been accepted by Kraepelin and 
many of his followers. For the sake of greater simplicity, and not to 
complicate for the student and general practitioner elements that are 
still debatable and full of confusion for psychiatrists, involution melan- 
cholia is here placed under the caption of manic-depressive insanity. 
Indeed, if the term manic-depressive insanity is to cover all that its 
originator claimed for it, it might well cover a disorder such as this, iu 
which we have no symptoms that are not to be found in the melancho- 
lias of other periods of life. While anxiety, for instance, is common in 
involution depression, it occurs at all ages, and, on the other hand, re- 
tardation, one of the cardinal symptoms of the depressed phase of manic- 
depressive insanity, is also observed in the involution psychosis. The 
three general and usual characteristics of this type of melancholia may 
be set down as depressed mood, fear, and anxiety. Doubtless, in so far 
as the physical changes incident to the retrogressive period of life are 
present in the patient, they modify or color the symptoms manifested. 

Symptomatology. — The prodromal symptoms are similar to those 
that precede the development of the depressed phase of manic-depressive 
insanity, as already described under that heading, possibly somewhat 
more deliberate in their evolution, owing to the age of onset. When 
the disorder is at its height, which is reached by gradual stages, we 
have, first, a profound depression, more or less stationary, shown in a 
sad or suffering expression, and in gentle weeping or loud wails of 
despair, with wringing of the hands, etc. Secondly, this general de- 
pressed state may be interrupted by anxious states, gradually increasing 
in intensity, or the change to the agitated condition may take place so 
suddenly as to be a raptus melancholic us. Ordinarily, the agitation 
shows itself in an unrest, varying in degree from restless walking to 
and fro to incessant running up and down, tearing the hair, and beating 
the breast. The anxiousness is almost always of the precordial variety. 
Thirdly, we have the development of delusions usually of sin or of 
unpardonable sin, sometimes of poverty, more rarely of reference. In 
addition to this ordinary delusional content, we may have added thereto 
delusions of a hypochondriacal or markedly paranoid nature, though 
these last are never systematized. Fourthly, in a goodly number of 
cases we note the presence of psychomotor inhibition, as described in 
the pages on manic-depressive insanity. Fifthly, illusions and hallucin- 
ations of sight and hearing, sometimes of taste and smell, are frequently 
manifested, and are especially important in the anxiety states, because 
of the dangerous and violent outbreaks they may induce. 

In all these cases there is a strong tendency to suicidal attempts, and 
the refusal of food is practically a constant symptom. 

Orientation, intellect, and memory are undisturbed, except in cases 
that go on through exhaustion into conditions of confusion or where 
they merge into stupor. 

These cases are usually divided into melancholia simplex, where there 
is neither delusion nor agitation, only a profound state of depression, 
melancholia anxiosa or agitata, in which the anxiety is predominant, and 



MANIC-DEPRESSIVE INSANITY. gQl 

melancholia stuporosa, in which the psychomotor inhibition is the strik- 
ing feature. To these qualifications are added hypochondriacal, religi- 
ous or persecutory, according to the delusional content presented. 

Course and Prognosis. — The involutional period of life influences 
the recovery-rate in this type of melancholia, so that fewer of these get 
well. Some forty per cent, recover fully. A certain number improve, 
some become chronic, and a majority of the rest die of some inter- 
current disease, especially tuberculosis. Suicide terminates the existence 
of a considerable number. 

Treatment. — Nothing need be added here to the general indications 
for the treatment of such cases given in the chapter on Treatment, and in 
the part devoted to the depressive phase of manic-depressive insanity. 
To protect from suicide by zealous supervision, to feed despite the re- 
fusal of food, to overcome insomnia by hydrotherapy, and, if need be, 
drugs, and to prevent exhaustion in the anxious cases, these are the 
main points that require consideration. 

51 



802 MENTAL DISEASES. 

CHAPTER VII- 
DEMENTIA PRAECOX, 

Dementia praecox is a disease beginning usually in early life, and 
characterized chiefly by a more or less marked and peculiar enfeeble- 
nient of the mind, but manifesting upon this basis a considerable variety 
of symptoms, such as emotional indifference, weakness of judgment, 
flightiness, verbigeration, automatic obedience, catalepsy, echopraxis, 
stereotypy, negativism, mutism, impulsive actions, affectations, grimaces, 
and unemotional laughter, delusions of a depressed or grandiose nature, 
and hallucinations. 

It is not easy to offer a brief and clear definition of dementia praecox 
and I have made the above from an analysis of Kraepelin' s descriptions 
of the multiform phases of this psychosis. He has brought together 
under this name a group of mental disorders, the distinguishing feature 
in all of which is a special type of dementia most clearly outlined in 
terminal conditions. 

There are cases in which all of the psychical functions are equally 
enfeebled, as in the disorder which we have been accustomed to call 
primary dementia, and which type is now included in the new category. 
These are exceptional. The characteristic of the enfeeblement of mind 
in dementia prsecox is the inequality of weakening of the several facul- 
ties, a sort of selective deterioration. 

Kraepelin includes in this large group of cases our old class of cases 
known as primary dementia, the catatonia of Kahlbaum, the hebephre- 
nia of Kahlbaum and Hecker, and the large group of cases that we in 
this country have been in the habit of calling chronic mania and chronic 
melancholia according to the nature of the delusions presented (grandi- 
ose or persecutory) and which are held by Kraepelin to be paranoid types 
of dementia praecox. True paranoia, or chronic delusional insanity, is 
not included. 

Classification. — This author, therefore, divides his group dementia 
praecox into three types of the disease, viz. : 

1. The hebephrenic type. 

2. The catatonic type. 

3. The paranoid type. 

Other authorities have made a still further division into five classes 
instead of three, as follows : 

1. Heboidophrenia. 

2. Hebephrenia. 

3. Catatonia. 

4. Paranoid. 

5. Mixed forms. 

It must be borne in mind that these types are more or less inter- 
related and often run into each other. 

Etiology. — Dementia praecox, according to Kraepelin, represents 
some fourteen to fifteen per cent, of all admissions to asylums, of which 



DEMENTIA PRECOX. 803 

five to six per cent, would represent the hebephrenic and catatonic types 
and nine to ten per cent, the paranoid group. In the statistics of the 
New York State hospitals for the year ending September 30, 1909, the 
total number of admissions of insane persons was 5149, and the 
diagnosis of dementia praecox, and states allied to dementia praecox 
was made in 1281 of these cases, nearly twenty-five per cent. 
In the statistics of Wolfsohn, of the Zurich asylum, dementia prsecox 
constituted nearly thirty per cent, of the admissions. This dis- 
order is essentially a disease of early life. In a study of 296 cases 
Kraepelin found that sixty per cent, began before the twenty -fifth year, 
though typical examples may be noted at any age. In the earlier years 
the disease is more apt to appear as a simple, gradually progressive 
dementia (hebephrenic type), a little later in adolescence as an acute or 
subacute form with catatonic symptoms, and still later as a paranoid 
condition. The two sexes are equally liable to the disorder, though 
there are more males affected by the hebephrenic form and more females 
by the catatonic and paranoid forms. Heredity was noted in seventy 
per cent, of the cases, and physical stigmata of degeneration are fre- 
quently to be observed. In ten to eleven per cent, of Kraepelin's cases 
the development of the disease was preceded by severe acute diseases, 
such as typhoid fever and scarlet fever, but, as usually, years had elapsed 
between the two episodes little value is to be attached to such relations. 
Alcoholism seems to have no place as a cause. It is noteworthy that 
more than six per cent, of Kraepelin's cases developed in prison. 

As to the pathological basis for dementia precox, Kraepelin is of 
the opinion that we have to deal with an actual chemical injury to the 
cortical cells causing their deterioration or destruction, and that the 
origin and development of the psychosis are best explained by the 
theory of an autointoxication arising possibly in connection with proc- 
esses going on in the sexual organs. He is led to the last idea by the 
unusually close association of the disease with the age of development, 
with menstrual disorders, and with pregnancy and childbirth. 

A theory evolved by Jung on the basis of the Freud psychology is 
that many cases are of psychogenic origin — that is, that they owe their 
origin to repressed emotional complexes, and, to account for the actual 
deterioration, he conceives that some toxin is ultimately created by the 
emotional condition. 

Another view which has perhaps wide credence is that the original 
impetus to psychical development implanted in an individual becomes 
prematurely exhausted, and the intellectual powers give out, dwindle, 
and disappear. 

Symptomatology. — Let us first take a view of the general symp- 
toms of dementia prsecox and later seek a mental grasp of the syndromes 
presented by the three types mentioned above. The underlying char- 
acteristic of psychical enfeeblement common to all has already been dwelt 
upon. 

The simple perception of external impressions is little, if at all, im- 
paired. The patient appreciates all that goes on about him far more 
than one would suppose from his behavior. One is surprised to learn 



g04 MENTAL DISEASES. 

that patients apparently wholly stupid and dull will take note of innu- 
merable remarks and events in their neighborhood, suddenly revealing 
their lucidity by some apt observation. 

In consequence of this, orientation is seldom disturbed in dementia 
prsecox. As a rule, the patient knows where he is, recognizes those 
about him, and clearly appreciates time. 

Hallucinations and illusions are common, especially in acute or sub- 
acute conditions. The auditory are most frequent, after which come 
hallucinations and illusions of sight and common sensation (feelings of 
currents passing through the body, of being touched, or of influences). 
These sensory symptoms tend at first to be of unpleasant nature and to 
distress and depress the patient, but are later received with unconcern, 
or at time's with amusement as if they were a species of theatrical per- 
formance. 

Consciousness is in many cases fairly clear throughout, though gen- 
erally somewhat clouded in excited and stuporous states. On the other 
hand, the faculty of attention is regularly subject to serious disturbance. 

One of the most prominent symptoms is the failure of interest. 
Though the patient perceives what takes place in his environment, he 
contemplates all with indifference. 

Memory is relatively little impaired in dementia prsecox, except after 
the lapse of years, when some reduction in the faculty may be noted. 

There is a retardation in thefloiv of thought, so that ideas are associated 
with difficulty even to the extent of an incoherence in which no possible 
connecting link can be perceived. But it must be conceded that this 
incoherence is often more apparent than real. It is very common to 
observe stereotypy of language, the senseless reiteration of phrases for 
days, weeks, months, playing upon words, rhyming, and other forms of 
verbigeration. 

The faculty of judgment is affected in all cases. Transitory or last- 
ing delusions develop in a very large number of cases. In the early 
stage of the malady the delusions are of depressed character, hypochon- 
driacal, melancholy, persecutory, but later on, grandiose ideas appear, 
either in association with the depressed ideas or displacing them. Such 
delusions, as a rule, are transitory, changeable, silly, and senseless, 
apparently because of the rapid advance of intellectual weakness. In 
the paranoid type they are less transitory and variable, but even here 
grow more aud more disconnected and less prominent as the disorder 
progresses. 

There are, as a rule, profound and striking disorders in the sphere of 
the emotions. An anxious or sad state marks the beginning of the disease 
in an extraordinarily large number of cases. Rarely there is mirthful- 
ness with constant laughing at this early stage. But more important 
than these transitory conditions of depression or exaltation is the invari- 
able development in this disorder of emotional deterioration. This, in- 
deed, is one of the fundamental characteristics of dementia prsecox. The 
failure of interest already alluded to depends in a measure upon the 
general emotional decadence, since the faculty of attention has an emo- 
tional foundation. The patient feels neither sadness nor joy. He is 



DEMENTIA PRECOX. g05 

indifferent to his relatives and friends, to his old occupations and pleas- 
ures, to pain, to fears, to desires. He is insensitive to injuries, to bodily 
discomfort, to uncomfortable physical positions, to pricking with a needle, 
but not always to hunger. The presence of food will often arouse an 
interest that is otherwise wholly lacking. 

This emotional indifference, together with deterioration of will-power, 
gives rise to numerous morbid manifestations in the domain of conduct. 
The patient is often practically will-less and has lost every ordinary incen- 
tive to normal behavior. He sits stupidly about, negligent of person 
and dress and of the demands of nature, or at times develops some sud- 
den imperative motor activity which may reach the degree of a stormy 
maniacal excitement. Impulsive actions, silly and senseless, often dan- 
gerous and destructive, are manifested, but wholly without will or pur- 
pose. They are the planless expression of an inner tension. Very often 
the automatic impulse will be reiterated over and over again in either 
language or conduct, constituting stereotypy. The patient will repeat 
the same words or phrases over and over again, or turn backward and 
forward or round and round, or move the hands to and fro, or take 
attitudes for hours. A very singular symptom in this connection is 
negativism. Every incentive to some sort of motor expression is met 
and overcome by a counter-incentive, by an inhibition. The will is 
blocked, as Kraepelin describes it ( WiMensperrung), To the category 
of negativism belong mutism; resistance to feeding, dressing, undressing; 
obstinate resistance to all that physician or nurse tries to do for the 
patient; the holding in of the saliva and excretions; the creeping under 
the bedclothes; the turning away when spoken to; the inaccessibility to 
all requests and influences. Negativism varies in extent and degree in 
various patients and often in the same patient. It is not uncommon for 
a condition of negativism, quite unsusceptible to outward influences, to 
be broken through by some sudden senseless motor impulse arising in 
the patient himself. After the impulse has been executed the patient 
relapses as suddenly into the former resisting state. 

With such reduction and perversion of the will in dementia prsecox 
it is not surprising to observe at times in every case some degree of sug- 
gestive automatism, such as echolalia, echopraxia, and catalepsy. 

Dementia prsecox is a psychosis that surprises the student and gen- 
eral practitioner by the singularly capricious and bizarre symptoms 
usually presented. They are altogether outside of his experience. In 
melancholia, for instance, we ordinarily observe only great exaggera- 
tions of psychological functions that are normal — a depression that goes 
beyond normal bounds. In mania, especially in the mild forms, the 
normal flow of thought, normal motor activities, and normal feeling of 
well-being are simply exaggerated, but to a degree that we recognize as 
pathological. In certain paranoid conditions and in paranoia the speech 
and conduct may be most of the time normal. It is in dementia prsecox 
that the extraordinary happens — the sudden motor explosions, impulsive 
actions, irrelevant laughter, stereotypy of speech and movement, negativ- 
ism, catalepsy, echolalia, echopraxia, neologisms, strange imperative ideas, 
the symptom of thought deprivation, and the saltatory fancies, affecta- 



806 MENTAL DISEASES. 

tions, mannerisms, and so on. Now, doubtless, all of these curious phe- 
nomena have their psychological explanation if we could only get at 
them. But much of the time such patients are practically inaccessible 
to us, and it is only at intervals and by the most careful study and 
research that we are occasionally enabled to obtain a glimpse of what 
goes on in their minds. There has been a great deal of investigation of 
the psychology of dementia prsecox of late, and much that is interesting 
has been discovered, and many psychological theories have been pro- 
pounded. The Kraepelin psychology is chiefly concerned with the idea 
of emotional deterioration, a selective dementia. Stransky, studying the 
problem on this basis, and finding constantly, especially in early stages, 
an incongruity between the emotions expressed and the ideas apparently 
behind them, formulated his theory of " intrapsychic ataxia," meaning 
simply thereby au inco-ordination between ideation and emotional tone, 
which leads to all the peculiarities of emotional expression and to pecu- 
liarities in the stream of thought, as evinced in incoherent speech and 
writing, with their stereotypies, assonances, etc. This inco-ordination 
may, however, be more apparent than real, for so difficult is it to gain 
access to the mind of the patient that we are not absolutely sure yet that 
the emotions are actually deteriorated, nor can we say with any certainty 
what idea rising from the subconscious is connected with the emotional 
expression we have just witnessed. It may be a normal co-ordination 
of thought and emotion, for aught we know. Weygandt, looking upon 
diminished power of attention as the chief symptom of the disorder, 
prefers the designation " apperceptive dementia," meaning thereby a 
dementia in which the power to take in, digest, and add to the intellec- 
tual store is lost. This would amount practically to a reduction in con- 
sciousness, almost a species of dream-state, and thus account for many 
symptoms like automatisms, stereotypies, etc. Gross has proposed the 
name " dementia sejunctiva " for the disease, based on his theory that 
we have in the disorder a disintegration or sejunction of consciousness. 
He explains that such disintegration of consciousness would mean the 
simultaneous flow of functionally separated series of associations. This 
would naturally lead to broken and disjointed associations, unrelated to 
each other, reaching consciousness in a bizarre manner, and thus give 
rise to such symptoms as autochthonous ideas, sudden impulses, hallu- 
cinations, ideas of thought-domination, imperative ideas, thought depriva- 
tion, saltatory fancies, etc. Pelletier finds an analogy between revery 
and dreams and dementia precox, in all of which conditions we have 
lowered attention and a shallow and sluggish flow of associations. 
Jung 1 has written an excellent monograph on the psychology of de- 
mentia prsecox, in which he discusses critically the work of psychologists 
in this field to date, and then builds up a parallel between this disorder 
and hysteria, and applies the principles of the Freudian psychology to 
dementia prsecox. He assumes many cases of this disease to be of 
psychogenic origin, to depend upon emotional complexes, and he makes 
a brilliant analysis of a case of the paranoid type as a paradigm. 

The physical disoi^ders of dementia prsecox have no pathognomonic 
1 Jung, C. G., " The Psychology of Dementia Prsecox," New York, 1909. 



DEMENTIA PRMCOX. gQ7 

value, though many have been studied and described. Among them 
are attacks of syncope ; epileptiform, apoplectiform, and hysterical 
seizures ; localized spasms ; tetany ; transitory paralyses ; aphonia ; sin- 
gultus ; choreiform movements ; " athetoid ataxia " ; aphasia; exaggerated 
reflexes and increased mechanical irritability of the muscles ; dilated 
pupils usually ; vasomotor disorders (cyanosis, oedema, dermographia, 
hyperidrosis) ; increased salivary secretion ; pulse slow or rapid, often 
weak and irregular ; subnormal temperature ; amenorrhea ; diffuse enlarge- 
ment of the thyroid gland ; anemia ; emaciation in acute and subacute 
conditions, but rapid increase in weight in later stages. 

Having thus passed over cursorily the general symptomatology of 
dementia prsecox, it remains to place before the student rather briefly 
the main features of the three marked types described by Kraepelin. 
The term heboidophrenia has been applied to the mildest degrees and 
moderate abortive forms of dementia prsecox, but the difference is so 
slight, being one merely of degree, between it and hebephrenia, that it 
hardly merits any fuller description here. 

THE HEBEPHRENIC FORM. 

This type is also called dementia prcecox simplex. It is a simple, 
progressive enfeeblement of the mind, varying in degree, and manifest- 
ing itself as a subacute, sometimes as an acute, psychosis. The earliest 
symptoms are almost neurasthenic in character, such as insomnia, head- 
ache, iu ability to work, and general feelings of fatigue and malaise. 
Gradually a change in character takes place. The patient becomes soli- 
tary, brooding, quiet, and indifferent to family, friends, recreations, and 
studies. Occasionally suggestions of delusional ideas are observed, de- 
pressive or hypochondriacal, ideas of being worthless, lost, going to 
pieces ; and at this stage the disorder is often looked upon by relatives 
as perversity of disposition rather than as disease. Paranoid ideas may 
be exhibited, suspicions, ideas of reference, of being watched, of being 
drugged, but always in a more or less rudimentary way. Grandiose 
ideas may come to the surface at times. There are often occasional 
single or solitary hallucinations. Sometimes the beginning is very sim- 
ilar to hysteria, so that the differential diagnosis is difficult. Again, the 
onset may either take on a strong depressive color or, on the other hand, 
a mildly hypomanic character. Single catatonic symptoms are some- 
times noted, and moderate negativism, minor mannerisms, and affecta- 
tions. Very characteristic and frequent is laughter without adequate 
cause. The further progress after the initial stage is manifested by 
growing apathy, emotional indifference, increasing loss of will-power, 
and defective judgment, but without any striking loss of orientation or 
clouding of consciousness. Some insight is often shown in the early 
period, the patient feeling that he is ill and changed from what he was 
before, and then expresses hypochondriacal ideas. The old memory- 
store is unaffected, but the power of adding new memories to it gradu- 
ally grows more and more defective. The emotional indifference grows 
apace, and is most noteworthy in relation to friends and relatives. 



808 MENTAL DISEASES. 

There is often an increased appetite and the patient is prone to grow 
stouter with the progress of the disease. The course of the disease is 
one of years, though at times the dementing process proceeds very 
quickly. Partial recoveries and remissions take place in a small per- 
centage of cases. The simulation by this form in the early stages of 
neurasthenia, hysteria, and the two phases of manic-depressive insanity 
must always be borne in mind in establishing the diagnosis. 

THE CATATONIC FORM. 

This type is distinguished as a progressive dementia, with the addi- 
tion of peculiar conditions of stupor or excitement, and with symptoms 
of negativism, stereotypy, and suggestibility (echolalia, echopraxis, waxy 
flexibility). When Kahlbaum first described his syndrome of catatonia, 
he included under that caption cases of melancholia with stupor, stupor- 
ous conditions, and acute dementia. 

The catatonic form is more common in women than in men, and is 
especially apt to set in after child-bearing. The prodromal symptoms 
and onset do not differ materially from those of the hebephrenic type. 
At first there are only now and then real catatonic manifestations, but 
as the disease progresses these become more and more manifest, with 
alternations of catatonic excitement and catatonic stupor. 

Catatonic excitement may develop suddenly, even sometimes out of 
the stuporous phase, and is marked by stereotypies, impulsive actions, 
mannerisms, negativism, great motor excitement of a bizarre or rhyth- 
mic nature, and verbigeration. Such patients often declaim theatrically, 
are destructive of clothing and objects in the room, resist violently any 
effort at control, and are filthy to a degree. Often there are marked 
sexual excitement, open masturbation, and obscene speech (coprolalia). 
Sometimes the excitement takes the form of an ecstasy. Occasionally 
it has a strong superficial resemblance to the psychomotor exaltation of 
a manic attack. 

Catatonic stupor may also develop suddenly in the midst of an excite- 
ment just described, or gradually in the course of the psychosis. Fully 
developed, it presents mutism, negativism, and tonic or negativistic 
muscular tension. The muscles of the mouth are often constricted and 
protruded forward in a peculiar way, so that the name Schnauzkrampf 
has been given to this symptom. The face is mask-like, but may be 
played over by stereotyped grimaces. The fingers and thumbs are 
strongly contracted into the palms. Patients in such condition have 
absolutely no reaction to stimuli, even painful pricks with a needle, and 
require to be fed forcibly and cared for in every way. 

The stupor may be suddenly transformed into excitement, or there 
may at any moment be a sudden explosion of extraordinary conduct or 
violence. There is a tendency to an irregular alternation of these phases 
in the course of the disorder. In less extreme cases we have moderate 
excitement or moderate stupor, varying with intervals when the chief 
symptoms are mannerisms, affectations, simple and quiet stereotypies, 
echolalia, echopraxis, etc. These conditions often last for long periods 



DEMENTIA PRECOX. 809 

of years. Hallucinations and transitory delusions of almost any variety 
are at times manifested. Very characteristic in this form are the remis- 
sions which may take place and last from a few hours to several weeks. 
In diagnosis it is necessary to differentiate the occasional manifesta- 
tions of catatonic symptoms in paresis, in epileptic states, in hysteria, in 
infection and inanition psychoses, in involution melancholia, and in senile 
dementia, and to distinguish the excited period from a manic phase. 
The mental enfeeblement is our strongest aid. 

THE PARANOID FORM. 

In hebephrenia and catatonia hallucinations and delusions are epi- 
sodic and transitory, subordinate to the simple enfeeblement in the one 
type and to the catatonic syndrome in the other. The paranoid type is 
characterized by a rapidly developing mental weakness with preservation 
of lucidity, and by a chronic delusional and hallucinatory state. 

Prodromal symptoms and onset are analogous to those in the other 
forms, but paranoid ideas are prone to develop quickly. They are never 
so elaborately systematized as in paranoia proper, though they may become 
more or less fixed and unchangeable in some cases, while in others they 
are often changeable, and of senseless and fantastic character. In many 
cases we observe symptoms reminiscent of the catatonic syndrome, and it 
is only the predominance of the delusional and hallucinatory symptoms 
that establishes the particular type. Besides paranoid ideas, we meet 
with grandiose delusions of an impermanent nature, and sometimes with 
hypochondriacal concepts. Neologisms and confabulation are often ob- 
served in this group. 

Kraepelin separates paranoid dementia into two main types : 

1. Dementia paranoides, with permanence of countless, disconnected, 
constantly changing persecutory and grandiose ideas, associated with 
moderate excitement. 

2. A type characterized by singularly fantastic delusions, innumer- 
able hallucinations and illusions, a more connected development, lasting 
a few years, and then terminating in confusion. 

Diagnosis as to All Forms. — Since dementia precox is essentially a 
disease of youth and adolescence, the majority of cases beginning between 
the eighteenth and twenty-eighth year of life, this is the first thought to 
come to the mind in the presence of a psychosis at this epoch of life. 
This age practically excludes forms of insanity like paresis, involution 
melancholia, and true paranoia (not usually fully developed till after 
thirty years of age). Other conditions that might come in question 
rarely would be hysterical and epileptic states and manic-depressive in- 
sanity. These can be excluded by a careful study of the symptoms and 
by the history of the patient. 

Prognosis in All Forms. — Since this is a dementing psychosis, the 
prognosis must be considered unfavorable from the first. At the same 
time a certain number do recover, and many improve, and a certain 
number have remissions, as in general paresis. Remissions seldom last 
long, the disease recurring in a short time, to remain permanently. 



810 MENTAL DISEASES. 

Treatment of All Forms. — It is possible that in time we shall be- 
come able to recognize prsecox tendencies in childhood, and learn methods 
of physical and mental training and psychotherapy that will help us to 
ward off in many cases the impending disaster. Certainly prophylaxis will 
have a great application here some time that it has not now. This would 
be of special value in the psychogenic cases. As to medicinal and other 
treatment, according to the symptoms presented, the reader is referred 
to the special chapter on Treatment. The fact that many of these cases 
are of perhaps psychogenic nature should lead us to be very careful in 
the early stages not to submit the patient, if it can be avoided, to the 
mental ordeal of asylum life, with its constant and suggestive contact 
with other patients, often worse off than himself. Isolation from the 
family will doubtless be advisable, but, if possible, among sane people, 
and where he can be given an occupation and exercise cure, which I 
have seen do more good in these cases than anything else. Such a sys- 
tem of cure should be in the hands of some intelligent and enthusiastic 
physician in the country. It is to be hoped that the urgent demand for 
home and family life with a physician in the country, who will take one 
or not more than two patients needing such care under his supervision, 
will be met ere long by an adequate supply. This system is well de- 
veloped in England, but with us is practically non-existent. 



CHAPTEK VIII. 

SENILE DEMENTIA AND OTHER SENILE PSYCHOSES. 

" Dementia " is a term employed to designate simply a general en- 
feeblement of all the mental faculties. It is often used improperly by 
the laity as synonymous with insanity. But in medicine it signifies 
only a general weakening of a mind once normal. Hence it is not 
applied to congenital mental weakness. The term " idiocy," with its 
various degrees, includes all of these congenital psychic defects. There 
are innumerable gradations comprised in dementia, from the merest 
dulness to profound deficiency or complete loss of all the intellectual 
faculties. Such enfeeblement of the mind may be the result of serious 
cerebral diseases or disorders, such as epilepsy, alcoholism, syphilis, etc., 
when the dementia is qualified as epileptic, alcoholic, syphilitic dementia, 
etc. It is sometimes, though rarely, a sequel to acute insanities, like 
mania and melancholia, and to chronic psychoses, like circular insanity 
and paranoia, and hence the distinctive term secondary dementia applied 
to such examples. It takes the chief part in the syndrome of paresis, so 
that that disorder is often entitled " paralytic dementia." Progressive 
mental enfeeblement not infrequently accompanies senile involution and 
organic changes in the brain incident to that epoch of life ; hence the 
well-known disorder called senile dementia. Finally, there is a form of 
mental disease characterized in the main from the very beginning by 
selective psychic enfeeblement, and this malady is classified as dementia 
precox. 



SENILE DEMENTIA AND OTHER SENILE PSYCHOSES. 811 

SENILE DEMENTIA. 

This is a progressive mental enfeeblement at the period of senile in- 
volution, dependent upon organic changes in the brain : therefore, a 
chronic organic psychosis. When the disorder begins before the sixtieth 
year and depends upon premature senility, it is sometimes called demen- 
tia senilis prcecox. 

Etiology. — Heredity has been noted in some fifty per cent, of the 
cases. Males and females suffer about equally. The disorder rarely 
appears before the sixtieth year. Mental stress and physical illness, 
together with the senile involution, are the chief etiological factors. In 
most of the cases arteriosclerosis takes part in the causation of the disease, 
inducing, as it does, general malnutrition of the brain, as well as frequent 
local degenerations of small or large extent. 

Symptomatology. — Like general paresis, senile dementia may mani- 
fest itself in protean ways, under the semblance of maniacal, melancholic, 
hypochondriacal, or paranoid types of psychoses, or by a simple progres- 
sive weakening of the mind, with only episodic appearance of delusions 
and hallucinations. The earliest symptom is failure of memory. The 
most recent memories disappear first in a sort of chronological order. 
After a time the patient fails to recognize any of his surroundings or 
any of the people about him. He converses with those near him, and 
miscalls them, as if they were old friends of long years ago. He lives 
over old events as if they were now enacted. Later on even these old 
memories vanish also. With failing memory, the judgment-associations 
perish. The patient commits many breaches of decorum, and later, 
with the degeneration of ethical feelings and the ascendancy of coarser 
instincts, may become very negligent, indecent, and unclean in habits ; 
may pilfer and destroy things; may expose his person, masturbate, or 
attempt liberties with little girls, etc. His loss of judgment may induce 
him to foolishly squander his money and properties. 

Illusions and hallucinations begin to manifest themselves. They are 
usually of terrifying character. 

Delusions make their appearance. These are nearly always perse- 
cutory in nature, and arise either as primary ideas or as the result of 
depression or on the basis of hallucinations. Next to delusions of 
persecution in frequency, we observe hypochondriacal delusions, with 
contents modified by the weak-mindedness present. Delusions of ap- 
proaching poverty are quite common. 

The underlying mood is often melancholic ; an exalted mood is ex- 
tremely rare. Changeability with irritability is perhaps the most usual 
affective condition. 

The behavior of these patients in relation to night is noteworthy. 
Illusions, hallucinations, delusions, and emotional states all become 
more pronounced at night. A striking feature, too, is extreme motor 
restlessness, especially at night. These patients try to get up from 
bed, to wander about the house, to get away from something or some- 
body. Sometimes true melancholic anxious states come on and lead to 
attempts at suicide. 

So far as bodily symptoms are concerned, we note foremost among 
them a general senile decrepitude, to which are added senile tremor of 



812 MENTAL DISEASES. 

the hands, and often various stigmata of focal lesions in the brain 
(aphasic and paraphasic attacks) ; sometimes hemiparesis, monoplegia, 
hemiplegia, apoplectiform and epileptiform attacks complicate the picture. 
The patients often complain of severe pains all over the body, of vertigo, 
ringing in the ears, sparks before the eyes, etc. Often, too, there is 
noticeable diminution of sensibility to touch and pain in various areas, or 
over the whole body. 

Intolerance to alcohol and a tendency to drunkenness are often early 
symptoms in a beginning senile dementia. The course of the disease 
may be divided empirically into three stages — an initial stage, a stage 
of well-marked general dementia, and the end stage. 

In the initial stage, which begins insidiously with a gradual decline 
of psychic functions, we note first the weakening of memory and the in- 
accessibility to new ideas and impressions, together with a slow change 
in character, manifested by irritability, egoism, excitement over trifles, 
easy weeping, childishness, and perhaps indecent and lascivous conduct 
(offenses against morals, exhibition, assaults on children). Often there 
is a condition of marked depression, showing itself in the form of a 
senile melancholia or a senile hypochondriasis. Sometimes the disorder 
begins with depression and suspicion, on which basis grows gradually a 
senile paranoid condition. More rarely there is a hypomanic state (senile 
mania). Whatever the character of onset, or psychotic coloring, in all 
these conditions the chief feature is the failing power of retention and 
adding to the memory-store. 

In the second stage the power of retention is wholly gone, and the 
patient lives only in years long past. Vocabulary and store of ideas 
gradually fail more and more, and disorientation as to time and place 
is complete. Still, during the daytime, despite these changes, the 
patient may automatically carry on his old life, read his papers, converse 
with family and friends, carry himself well, go to his meals regularly, 
play cards, etc., but often at night he is restless, sleepless, completely 
disoriented, sometimes delirious and hallucinated, with amnesia for these 
experiences when the day comes again. At times we meet with confab- 
ulation, and a condition reminding one of the Korsakoff psychosis. 
This state is sometimes designated as senile Korsakoff ' s psychosis. 

The third stage is that of profound dementia, terminated by general 
physical disintegration and death from disorders incident to old age. 

Course and Prognosis. — Senile dementia develops gradually upon 
the basis of senile psychic degeneration, and lasts, ordinarily, from 
three to ten years, sometimes with remissions which are never so note- 
worthy as the remissions of paralytic dementia. In rare instances an 
acute course is taken, the disease terminating by death in a few months. 
Paralytic attacks are not infrequently observed in the course of the 
malady, giving it a certain analogy to paresis. The prognosis is unfavor- 
able, as the disorder is incurable and progressive to a fatal end. 

Diagnosis. — The most important indications for diagnosis are defects 
of memory and judgment and acts dependent upon loss of ethical feeling. 

Pathological Anatomy. — We observe at autopsy chiefly the follow- 
ing conditions : 

1. Osteophyte deposits on the inner surface of the skull. 



PARALYTIC DEMENTIA. 813 

2. Pachymeningitis hemorrhagica interna (more frequently even 
than in paralytic dementia). 

3. Opaque and thickened leptomeninges. 

4. Increased fluid, subdural, and in the meshes of the pia-arachnoid. 

5. Distention of the ventricles with serum, and granular ependyma. 

6. Extreme narrowing of the cortex, with gaping sulci. 

7. General endarteritis deformans (often with foci of softening and 
hemorrhage). 

8. Wide-spread degeneration of ganglion-cells and association fibers. 
Treatment. — Many cases of senile dementia can be treated at home. 

It is only when tendencies to suicide, sexual immoralities, waste of 
property, and great ideomotor excitement are exhibited that commitment 
is necessary. The bromids are the best hypnotic for these cases. 
Paraldehyd is extremely useful, too, since it is efficient as a hypnotic 
and does not injure the circulation or affect the digestive apparatus. In 
melancholic phases opium acts well. Hyoscin and its congeners are not 
to be recommended because of their depressing action on the heart. 

OTHER SENILE PSYCHOSES. 

Some of these have already been referred to above. Besides the 
dementia which may be au evidence of premature senility, we some- 
times have a presenile paranoid condition developing before the sixtieth 
year, especially in women. It begins like other paranoid conditions, 
finally developing into a psychosis with delusions often of a peculiar and 
extraordinary nature (colored thus by weakmindedness), and in content 
persecutory, though sometimes delusions of infidelity are present. The 
persecutory ideas never become fixed or systematized, but are remarkable 
for their changeability and evanescence. They do not affect the conduct 
of the patient, and are often corrigible by argument, but only to return 
in some other form. The condition tends to become chronic and without 
dementia. Recovery almost never takes place. 

We may meet with various alcoholic psychoses after the age of sixty. 
I have seen a considerable number of cases of epilepsia tarda after that 
age, sometimes with mental symptoms. It is not infrequent to meet 
with psychoses that are the result of organic diseases of the brain in old 
age, associated, for instance, with hemorrhage and thrombus. It must 
be remembered, too, that real dementia prsecox, manic-depressive in- 
sanity, and even paresis may at times develop in the period of senility. 
It is not uncommon to meet with infection, exhaustion, and toxic deliria 
in old age. 

CHAPTER IX. 
PARALYTIC DEMENTIA. 

Synonyms. — Dementia paralytica ; Progressive general paralysis ; General paresis ; 
General paralysis of the insane. 

Definition. — Paralytic dementia, as its name implies, is a disorder 
characterized chiefly by progressive enfeeblement of the mind, together 
with a progressive general paralysis of the whole body. It is essen- 



814 MENTAL DISEASES. 

tially a cortical disease, but its symptomatology is frequently modified 
by spinal complications. The psychic symptoms, in addition to the 
characteristic progressive dementia, present multiform phases, neu- 
rasthenic, hysterical, hypochondriacal, melancholic, maniacal, circular, 
paranoiac, etc. An expansive phase with delusions of grandeur is very 
common at one period or another in the course of the malady. 

Etiology. — Intellectual overwork or strain, working on a founda- 
tion impaired by syphilis or alcoholism, or both, may be said to be the 
chief cause of general paresis. Heredity, undoubtedly, plays a part in 
the causation of this form of mental disorder, though perhaps not so 
great as in other classes of insanity. The role of heredity has been 
variously computed at from ten to forty per cent. As regards sex, it may 
be stated that on an average, among all classes of society, twelve times as 
many males as females are affected — the disproportion seems to be less 
among lower orders of people. The age of onset is usually during the 
fourth or fifth decad, bespeaking in general the climacteric period of 
human life. But general paralysis may be encountered at almost any 
age. Nearly one hundred cases have been recorded as occurring in 
children. Occasionally late cases are met with after the age of sixty. 
It is a common disease in the great centers of civilization, where the 
intellectual stresses are most severe, and is comparatively rare among 
lower races. For instance, it is seldom observed among the native 
Egyptians or Icelanders. The disease is more frequent among men of 
ability in professional or business life than among the ignorant and un- 
cultured. 

As regards the position of syphilis as an etiological factor, it may be 
said that a certain history of syphilis is obtainable in at least fifty per 
cent, of the cases, and it is probable that the true relation is considera- 
bly larger. Several years ago, in a study of this subject, I examined 
the contributions of no fewer than seventy authors to the elucidation of 
this problem. There was wide divergence in the statistics presented ; 
but from my examination of all these figures, it was assumed that be- 
tween sixty and seventy per cent, of all cases of general paralysis were 
syphilitic, if not far more. 

By a comparison of statistics of the relation of syphilis to all other 
forms of insanity, which I have estimated to be from six to ten per 
cent., we have the further fact that syphilis is seven to ten times as fre- 
quent in dementia paralytica as in insanity in general. 

The fact is thus established beyond dispute that syphilis is a striking 
etiological factor in general paresis, and many modern authorities have 
come to look upon it as a true parasyphilitic disease. 

A much more difficult problem is to determine the exact nature of 
the relationship between syphilis and general paresis. Is it a direct 
cause, or merely a contributing agent ? Is it in syphilitic cases a post- 
syphilitic affection, or is foregone syphilis merely a predisposing factor ? 
The problem may be examined from several standpoints. In the first 
place, we have the rather remarkable statistics of Lewin of 20,000 
cases of syphilis, one per cent, of which became insane, and in which 
not a single case of general paresis developed. Then we have the 
further fact, to which I have already alluded, that among the native 



PARALYTIC DEMENTIA. 815 

Egyptians, where syphilis is one of the most widespread of disorders, 
scarcely a case of general paresis has been reported ; and in the asylums at 
Cairo, which I visited a few years ago, not one such case was to be found. 1 
It is significant, by the way, that alcoholism is seldom or never observed 
among them, the drinking of spirituous liquors being interdicted by the 
Koran. Such facts as these it is impossible to reconcile with a hypoth- 
esis ascribing to syphilis the direct causation of paralytic dementia. 

In a recent visit to Japan, I found that in the asylums the percent- 
age of admissions of paretics is high, — quite as high as in our American 
asylums, — but alcoholism is practically unknown ; that is, such a thing 
as delirium tremens has seldom been seen by a Japanese physician, 
while Korsakoff's psychosis is an unknown entity. This would mean 
that in Japan syphilis without alcohol is the chief cause of paresis. 

Again, from the pathological standpoint, it is well known that the 
direct invasion of the brain by syphilis is characterized by changes in 
the blood-vessels (endarteritis obliterans), by the formation of gum- 
mata, or by diffuse meningeal infiltration (specific leptomeningitis or 
meningo-encephalitis). The first and third of these processes are most 
frequent in and about the base of the brain. The second is more com- 
mon in cortical regions. On the other hand, in general paralysis we 
have a chronic meningitis of the convexity with atrophy of the cortex, 
and the processes in this disease and in syphilis are quite distinct, 
although there are cases in which a syphilitic meningo-encephalitis may 
closely simulate symptomatically dementia paralytica. The pathological 
processes are different. 

The best recent English exposition of the relationship of syphilis to 
general paresis is by Dr. Frederick Mott, in the "Arch, of Neurology," 
published by the Pathological Laboratory of the Loudon County Asylums, 
Vol. I. He does not consider the dictum " no syphilis, no general 
paralysis," proven, but believes all the evidence is in favor of the strong 
influence of syphilis in its production, and brings forward this evidence 
in a convincing way. One of the most cogent reasons is to be found in 
his study of twenty-two cases of juvenile general paralysis occurring 
from the age of eight to twenty-three years. Syphilis could not be ex- 
cluded in any of these, but was positively determined to be present in 
thirteen cases, and in the parents in four, making a total of eighty per 
cent. He feels, however, that all were syphilitic. Dr. Mott considers 
the pathological process in both tabes and general paralysis to be ident- 
ical, and agrees with Mobius, who calls them metasyphilitic, the same 
disease affecting different parts of the nervous system. Since my own 
studies of this subject in 1892, I have devoted more than usual atten- 
tion to an extremely careful examination of the history and of the 
bodily conditions in paretics in whom syphilis was denied, and feel sure 
that the percentage is much higher than the figures given by me at that 
time. There are still some few cases in which it is not possible to dis- 
cover, either upon the person or in the history, any evidence of previous 
syphilis, but we know that patients are often seen in whom the specific 

1 Since the above was written several articles have appeared noting the existence 
of general paresis among the Egyptian fellaheen, though not to any such extent as 
prevails among the higher races. 



816 MENTAL DISEASES. 

infection has been so mild in character that no residua are left upon their 
persons, and they have no memory of initial lesions, yet the conditions 
are such that they must have had syphilis. As Mott says, women, for 
instance, are often infected and have no characteristic lesions. They 
may be immunized by a spermatically infected fetus, so that they have 
the disease in so mild a form that there is no noticeable impairment of 
health. 

Alcohol would seem to be a factor in some twenty per cent, of par- 
etics. Other toxic agents (lead, tobacco, rheumatism, etc.) are also be- 
lieved to take a part at times in the etiology. Trauma has often been 
mentioned as an occasional cause of paresis, but there is no well-authen- 
ticated instance in literature of such etiology, and until better evidence 
is oifered we must doubt the sufficiency of this factor. 

In most cases, as already intimated, several of the causes named are 
associated in the production of the disease. 

Symptomatology. — The disease is best studied in its three stages 
— the prodromal period, the established disorder (which may be exalted, 
depressed, or hallucinatory), and the terminal period of dementia. 

Prodromal Period. — General paresis is one of the most insidious 
forms of insanity as regards its gradual, almost unnoticeable onset. 
Very often this early stage presents symptoms which lead to its being 
mistaken for neurasthenia. Indeed, the earliest symptoms may be 
neurasthenic in character, or even a combination of hysteria with neu- 
rasthenia. Sleeplessness, tremor, irritability of mood, hypochondriacal 
depression, dull headache, ophthalmic migraine, pains in various parts 
of the body, general malaise, loss of appetite, and digestive disorders — 
these are the manifestations which may be readily misinterpreted as 
purely of functional nature. It is only when other symptoms in ad- 
dition to these are presented that a suspicion of a more serious malady 
may be entertained or the diagnosis actually established. These symp- 
toms are, on the mental side : little faults of memory ; errors in speech or 
writing ; the misuse of Avords ; the leaving out of letters, syllables, or 
words, or their reduplication in writing ; growing indifference to the 
higher sentiments ; loss of the critical faculty ; small lapses in the pro- 
prieties, and failure of interest in the more important affairs of life. As 
these mental features become more and more pronounced, the patient 
loses and mislays things, makes mistakes in money matters, errs in ap- 
pointments, confuses persons and objects, forgets his way, becomes 
easily angered, markedly offends the proprieties, shows extravagance in 
the use of money, evinces distinct loss of the ethical feelings, exhibits 
proclivities to sexual and alcoholic excess, and becomes negligent of his 
dress. 

In the earlier period the patient, like any neurasthenic, has a dis- 
tinct consciousness of his own illness and observes his symptoms. But 
with the progress of the malady — and it is in this that we find an im- 
portant contrast to the course of neurasthenia — he loses that sense of 
being ill, takes no further notice of his own symptoms. On the physical 
side there are a number of significant marks which are helpful in mak- 
ing an early diagnosis : defective innervation of one side of the face, 
causing a slight paralysis ; transitory ocular palsies, diminished sensibility 



PARALYTIC DEMENTIA. 817 

to pain, Argyll-Robertson pupils ; diminished, lost, or exaggerated 
tendon-reflexes ; a dark, pale, greasy complexion ; lack of facial expres- 
sion ; jerky tremor of the faciolingual muscles at the beginning of 
voluntary movement ; slight difficulties of articulation ; rustlings of 
blood to the head, and attacks of syncope or of mild or severe epilepti- 
form convulsions. A number of other early symptoms have been 
described by various authors to which some value attaches : loss of 
memory of localization of tactile sensations (Ziehen) ; loss of the 
cremasteric reflex ; testicular insensibility ; peculiar respiration, with 
short inspirations, followed from time to time by prolonged sighing 
expirations (Regis) ; gastric and vesical crises (Hurd) ; calcification of 
the sternum, with incurvation of the xiphoid appendix and consequent 
interference with thoracic breathing (Regis). 

Period of Establishment of the Disease. — When the disorder is 
fully established after a prodromal period which may range over months 
or years, it is marked by both physical and mental symptoms which are 
usually characteristic : 

Chief Physical Symptoms. — (1) Peculiar articulation and writ- 
ing — the " paretic speech " and " paretic writing " ; (2) tremor ; (3) 
pupillary disorders ; (4) lost or exaggerated tendon-reflexes ; (5) mus- 
cular weakness ; (6) apoplectiform and epileptiform crises ; (7) emacia- 
tion ; (8) trophic disorders. 

Mental Symptoms. — (1) Failure of memory for both recent and 
old events ; (2) diminishing number of concrete, abstract, special and 
general ideas ; (3) weakening of judgment ; (4) loss of sense of time 
and place (lack of orientation) ; (5) delusions (marked by enormous 
exaggeration, whether exalted or depressed) ; (6) hallucinations and illu- 
sions ; (7) emotional irritability ; (8) exalted, sometimes depressed, 
mood ; (9) loss of ethical and esthetic feeling. 

We will now examine these symptoms somewhat in detail. 

The paretic speech is so characteristic that, heard a few times, it is 
always remembered ; yet it is difficult to describe. There are shades 
of difference in various individuals, so that authors qualify the disorder 
of speech as drawling, stammering, hesitating, scanning, spasmodic, 
ataxic, and so on. It has some resemblance to the speech of a drunken 
man. Doubtless the main seat of the lesion affecting the speech of the 
paretic is in the cortical motor speech-center, but sometimes the lesion 
is probably in the bulbar centers connected with the elaboration of the 
motor impulses requisite to articulation. The jerky tremor or ataxia 
of the speech-muscles, together with incoordinated impulses from the 
cortical motor speech-center, is responsible for the peculiarities in 
speech. Labials and certain consonants are the most difficult for the 
paretic to enunciate, and the typical speech is shown in the attempt to 
pronounce such words or phrases as " electricity," " artillery and cav- 
alry brigade," " immovability," etc., in which the consonants may be 
left out, drawled over, misplaced, or even reduplicated thus : " elec- 
tericity," " artillililery," " bigrade," " immobilty." As the disease 
advances, the words are run more and more together, until finally the 
speech is utterly incomprehensible. 



818 MENTAL DISEASES. 

The hand writing of the patient is of equal, and in the earliest 
stages even of greater, importance. Lapses of words, repetitions of 
words or even sentences, and especially elisions and reduplications of 
letters or syllables are extremely significant. 

The tremor in paretics affects all parts of the body, but is especially 
noteworthy in the face and tongue. In the tongue it often takes on a 
fine, fibrillary character. It is very rare in even pronounced neuras- 
thenic conditions to observe tremor of the facial muscles. Still we do 
meet with it at times, and the distinction that I would draw between 
the facial tremor of profound neurasthenia and that of paresis is that 
in the latter disorder there is a peculiar jerkiness and ataxia in the 
tremor, especially at the beginning of a voluntary movement. Thus, in 
asking the paretic to wrinkle his forehead, an ataxic tremor will be set 
up in the occipitofrontalis. In snarling up the nose, it is observed in 
the small muscles about the cheek and nose. In showing the teeth, the 
ataxic tremor becomes marked in the levators of the lip. In protrud- 
ing the tongue, there is a rapid, jerky tremor at the beginning of the 
movement. 

As regards the pupils, the most important sign is absence of the 
reflex to light. Next in order comes extreme miosis (pin-hole pupils), 
and next in importance a variable inequality (one pupil being larger at 
one time and the other at another time). Irregularity of outline of 
either or both pupils is significant. Simple inequality of the pupils is 
less distinctive because met with in other forms of insanity, and occa- 
sionally in normal persons. Marked mydriasis is very common in the 
latest stage of the disease. 

In tabic forms of the disorder the knee-jerks are diminished or lost. 
In all other forms the tendon-reflexes are apt to be enormously exag- 
gerated, so that we get not only extreme knee-jerks, but quadriceps 
clonus, ankle-clonus, jaw-jerk, jaw-clonus, and extreme wrist- and elbow- 
jerks. With this spastic condition we observe also considerable rigidity 
of the muscles, with a tendency in the latest stage to marked contrac- 
tures. Often in tabic forms, when the knee-jerks are at first lost, they 
become finally exaggerated. Hence, while the term tabic is often used 
to describe a form of paresis in which we have lost or diminished knee- 
jerks, together with Argyll-Robertson pupils, this is simply a descriptive 
designation, and does not necessarily imply that we have a combination 
of locomotor ataxia with paresis. 

As previously stated, one of the chief symptoms of paralytic de- 
mentia is a progressive weakening of the muscles in general of the 
whole body. It is rather an enfeeblement than a paralysis. It is 
manifested mainly by localized pareses in various muscles or groups of 
muscles. These are often noted as early symptoms — for instance, in the 
eyes and face. In fully one-half of the cases we observe, at one time 
or another, weakness of some of the ocular muscles, not infrequently 
giving rise to diplopia or ptosis, rarely nystagmus. A certain amount 
of ptosis is often seen, and the overaction of the occipitofrontalis in 
consequence forms a striking picture in many cases. One-sided paresis 
of the forehead muscle, orbicularis palpebrarum, or lower face is rather 
common. The muscles about the mouth are particularly often involved,. 



PARALYTIC DEMENTIA. 819 

so that marked inequality of the nasolabial fold and of all of the oral 
movements is encountered. The speech has frequently a nasal tone 
from one-sided or double palate paralysis. Deviation of the tongue is 
common. The general strength of the extremities, as measured by dyna- 
mometers, is diminished, sometimes on one side more than on the other, 
presenting the picture of a hemiparesis. The want of equal innervation 
is sometimes indicated by the attitude of the patient, the inclination of 
the body to one side or another, backward or forward, sinking of the 
head on the breast, etc. Weakness in the muscles of deglutition leads to 
difficulty in swallowing. The peculiarity of most of these paralytic phe- 
nomena is, in the first place, their mildness of degree, and, in the second, 
their frequently transitory character (the weakness may be first on one 
side of the face, then on the other, now about one eye, now in an ex- 
tremity, etc.). 

Nearly every case of general paresis exhibits, at some time in its 
course, convulsive or apoplectiform seizures. Usually these critical 
episodes occur at the height of the disorder or in its final stages, but 
occasionally they are among the very earliest symptoms. For instance, 
one case that came under my observation began with a transitory hemi- 
plegia following an apoplectiform attack. Up to the day before this 
seizure he had performed his difficult duties as an accountant in a large 
railroad organization to the perfect satisfaction of his superiors, and 
none of his family had observed any indication of prodromal symptoms. 
He died as a typical paretic a year later. Another case, much the same 
in many ways, began with general epileptiform convulsions extending 
over twenty-four hours. The attacks may appear in the form of syn- 
cope, or coma, or aphasia. A peculiarity of all of these crises is their 
transient character, and as even in cases terminating fatally in such 
attacks often no lesion has been found, their pathogeny has been 
ascribed to congestive conditions or to circumscribed edemata in various 
areas of the brain. As a rule, mental failure becomes more apparent 
after these crises. 

Eapid emaciation is usual after the disorder has actually set in, — that 
is, at the termination of the prodromal period, — but later on, -after the 
climax has been reached and dementia becomes more apparent, patients 
often gain largelv in flesh. 

Among the trophic disorders we note especially bed-sores, which 
appertain mostly to the terminal condition. In some of the cases a true 
trophoneurosis is the cause, and in others weakened peripheral circula- 
tion and imcleanliness. A striking fragility of the bones is common in 
general paresis, which accounts for numerous accidents in asylums, such 
as fractures of the ribs and other bones, exploited so often in the news- 
papers as due to the assaults of attendants. I have known a maniacal 
paretic to break all of the small bones of his hand by pounding on a 
door. Hematoma of the ear is very frequent in paralytic dementia, 
and this must be ascribed to trophic changes in the vascular walls, per- 
mitting some trivial trauma to cause a rupture in the vessels of the peri- 
chondrium. The hair frequently becomes rapidly gray in paresis, and 
this, too, is doubtless a trophic symptom. 



820 MENTAL DISEASES. 

Among other physical symptoms occasionally met with are to be 
mentioned changes of temperature, alluded to in the chapter on General 
Symptomatology, intermittent albuminuria, propeptonuria, glycosuria, 
acetonuria, polyuria, impotence, and vesical and rectal weakness. Gly- 
cosuria is sometimes an early symptom. 

As regards mental symptoms, the gradual and progressive failure of 
memory, and, as a consequence, the progressive depletion of the store 




Fig. 311. — A group of paretics. Taken to show exalted and melancholic phases (Dr. Atwood). 

of memory-pictures, ideas, idea-associations, and judgment-associations, 
are the most noteworthy features of the disease. The most complicated 
conceptions, as well as those acquired latest, are the first to disappear. 
Abstract ideas, owing to their complexity, are the earliest to go. The 
patient loses his memory for dates, for the events of to-day and yester- 
day, and finds difficulty in remembering his appointments and duties. 
A very early loss of the power of mental computation is notable. With the 
progress of the malady, even the older memories and concrete ideas 
vanish by degrees. The patient comes to have no knowledge of time, 
the place where he is, or of the friends who surround him. The loss 
of the faculty of judgment is evident at an early period in his failing 
observation and comprehension of his own symptoms. Ordinarily 
there is a retardation of the flow of ideas, particularly marked in the 
melancholic type of the disease. In the exalted type there is an accel- 
eration of the flow of thought, which is given a special color by the 
mental enfeeblement. 

There are cases which run their course without delusions, the symp- 
toms then being merely the progressive dementia with advancing physi- 
cal debility. But in a considerable proportion of paretics delusions 
are manifested, usually of grandiose character, associated with more or 
less ideomotor excitement (sometimes approaching the maniacal condi- 
tion), and occasionally of melancholy character. The grandiose ideas 
of male patients are concerned with wealth, power, glory, size, strength, 
position, possessions, and of female patients with dress, finery, jewels, 



PARALYTIC DEMENTIA. 821 

and children. At an early period these grandiose ideas are not to be 
distinguished from the similar fancies of many cases of ordinary acute 
mania. But when the judgment becomes weakened, as it inevitably 
does, a peculiarly distinctive character is given to the paretic's delu- 
sions. The grandiose delusions take a magnitude, an enormity, a stu- 
pendousness not observed in any other form of insanity. Wealth is 
counted in decillions of worldfuls of gold. The patient is czar, king, 
president, queen, God, at the same time. His penis is a mile long, 
his testicles large diamonds. He will bring the Pacific Ocean over 
the Andes to make the largest waterfall in the world. He will 
move the asylum buildings on a road of gold to Washington. He 
has thousands of wives, every one of whom bears two hundred children 
nightly. He bestows on his physicians and nurses royal orders, duke- 
doms, writes them checks for enormous sums of money, etc. When 
the mood of the patient is hypochondriacal or melancholic, the delu- 
sions retain the same element of enormity despite their unhappy 
contents. He states that he is impoverished by having lost billions of 
dollars ; he is committed to prison for thousands of years ; he weeps 
because he can not do his duty to the nations which he governs ; there 
is some horrible condition of his bowels which requires the most awful 
of operations, etc. - 

There are some cases of general paresis which exhibit alternating 
phases of melancholic depression and ambitious exaltation, and these are 
described as paralytic dementia of circular type. 

Hallucinations and illusions are frequently observed in general 
paresis. They have more or less relation to the condition of exaltation 
or depression present and to the delusions manifested. Auditory hallu- 
cinations are the most common. They are noted even in the early 
periods of the disease, but are generally a part of the maximum period. 
Thev are absent in the final sta^e. 

Emotional irritability and changeability are generally evident. The 
patient laughs or weeps easily, and is often readily angered. 

The excesses, sexual and alcoholic, lapses of propriety, etc., are sig- 
nificant of loss of esthetic and ethical sensibility. He indulges him- 
self freely and without morality (though previously moral), drinks im- 
moderately, steals, and squanders his own and others' property. As 
his character sinks lower and lower he commits all sorts of shameless 
offenses against decency. 

Before passing on to the final stage, we not infrequently encounter, 
in the course of the disorder, peculiar interludes of recession of all of 
the symptoms. These are known as remissions. Bemissions last from 
several weeks to several months, as a rule, occasionally for a year or 
more. Very striking at times is the remarkable improvement to be 
observed in a remission. This may attain to a degree making it almost 
impossible to discover any vestige of deviation from the patient's normal 
mental health. The extraordinary delusions disappear, the maniacal or 
melancholic mood vanishes, the symptoms of confusion and forgetfulness 
pass away, and noteworthy intellectual lacuna? are filled again. The 
patient may return to his affairs. It is very rarely that marked physi- 
cal stigmata of the disorder diminish and give place to normal con- 



822 



MENTAL DISEASES. 




ditions. After a time the old symptoms of the dread malady reassert 
themselves and its fatal progress is rebegun. 

Terminal Period. — As already intimated, there are cases in which 

there is merely a progressive en- 
feeblement of mind and paresis of 
body from beginning to end, with 
none of the excited or depressed 
conditions, delusions, hallucinations, 
remissions, etc., just described ; cases 
which pass by gradual stages from 
the prodromal into the terminal 
period. In the main, however, we 
have most of these other manifesta- 
tions interpolated. The final stage 
is often ushered in by the convul- 
sive or apoplectiform seizures. This 
is the stage of more or less com- 
plete dementia. We may still note 
the remains of old grandiose or 
hypochondriacal delusions in the 
scarcely comprehensible mumblings 
of the paretic dement, but usually 
the mind becomes completely vacu- 
ous ; the patient speechless, filthy 
in his habits, bedridden, and more 
helpless than an infant. He lies in 
bed, either motionless or restlessly 
moving his limbs and grinding his 
teeth. He can scarcely swallow his food, and often requires to be fed 
to prevent strangling. He wets and soils himself, and bed-sores and 
contractures develop. Finally, death by inhalation-pneumonia, septi- 
cemia (from the bed-sores), cystitis, marasmus, intestinal catarrh, or ex- 
haustion steps in to draw the curtain on the distressing picture. Not a 
few die at an earlier period in an epileptiform or apoplectiform crisis. 

Duration and Prognosis. — Paralytic dementia runs its course in 
three to five years, on an average. There are more cases which termi- 
nate under three years than over five, but cases lasting five years are 
not infrequent. A duration of ten years is among the greatest 
rarities. 

The prognosis is practically always death within a short term of 
years. The author has never known personally of a case recovering. 
In our whole literature there are, according to Ziehen, but a dozen 
cases of recovery on record. It is probably questionable if even these 
were genuine cases of paresis, since an error in diagnosis is not at all 
uncommon. 

Diagnosis. — The chief disorders which may be confused with 
paralytic dementia during the various stages of its evolution are 
neurasthenia, alcoholism, syphilis of the central nervous system, acute 
mania, epileptic dementia, paranoia, or secondary paranoia with delusions 
of grandeur, multiple sclerosis, and mental conditions associated with 



Fig. 312.— A noted actor -who recently died 
of paresis. Taken to show the expression of 
paralytic dementia in an unusually expressive 
face (loaned by Dr. Atwood). 



PARALYTIC DEMENTIA. 



823 



common organic lesions of the brain (tumor, hemorrhage, embolism, 
thrombosis). In atypical cases the diagnosis is often difficult and 
sometimes even impossible. 

Valuable aids to our methods of diagnosis are found in lumbar punc- 
ture and a study of the spinal fluid, to show the presence of a lymphocytosis 
characteristic of paresis^ as compared with any of the functional psy- 
choses ; also in the Wassermann test and the JNoguchi test for syphilis. 

As regards neurasthenia, it is only in the prodromal period of gen- 
eral paralysis that differentiation may be difficult. I shall attempt to 
present in brief, tabular form the distinctive diagnostic points of these 
two conditions : 



Gexeral Paeesis (Eaely Peeiod). 

Sluggish, immobile^ irregular, piu-hole, 
or unequal pupils. 

Diminished, greatly exaggerated, or un- 
equal knee-jerks. 

Fibrillary tremor of tongue ; jerky, 
ataxic tremor of fingers, face, 
tongue, occipitofrontalis. 

Elision or reduplication of letters, syl- 
lables, or words in writing. 

Sometimes noticeable characteristic de- 
fects in speech. 

Usually little or no notice taken by the 
patient of his symptoms. 

In some cases a feeling of cheerfulness 
and well-being out of proportion to 
the actual disorder present. 

In many cases a vague, hypochondriacal 
depression with tearfulness, not 
referred to any definite physical 
cause. 

Actual evidence generally found of fail- 
ing memory, defect of intellectual 
process, weakened judgment, and 
loss of esthetic and ethical feeling. 

Occasionally epileptiform or apoplecti- 
form crises. 

Vertiginous attacks and transitory apha- 
sia of mild desree. 



Neueasthexia. 
Large and rather active pupils usually. 

Active and equal tendon-reflexes. 

Tremor fine and rapid of fingers and 
eyelids, not jerky, very rarely in- 
volving face, almost never the 
tongue and forehead. 

Nothing abnormal in the writing. 

No changes in enunciation. 

Patient pays marked attention to his 

symptoms. 
Patient apprehensive and alarmed at 

any symptoms present. 

When hypochondriacal, patient's atten- 
tion fixed on some definite morbid 
process which he believes to be 
going on in his system. 

No evidence of mental decay or loss of 
esthetic and ethical feeling. 



Nothing of this kind in neurasthenia. 
Not present in neurasthenia. 



In chronic alcoholism we may have presented to us many symptoms, 
such as tremor, thick speech, mental changes and defects, epileptiform 
crises, and, where rudimentary polyneuritis is present, lost knee-jerks, 
which may simulate the syndrome of paralytic dementia. The resem- 
blance is sometimes remarkably close. The chief differential point is 
the great improvement and often recovery which take place in alco- 
holic mental disorder on withdrawal of the alcohol. With abstinence 
the speech becomes normal, the tremor grows less or disappears, the 
knee-jerks return, epileptiform attacks cease, defects of memory are no 
longer perceptible. If hallucinations are present, they are more often 
visual and zooscopic in alcoholism, while generally auditory in paresis. 
The delusions of the chronic alcoholic are, as a rule, suspicious and per- 
secutory. It must be remembered that a typical general paresis may, 
however, develop on the basis of a chronic alcoholism. 



824 



MENTAL DISEASES. 



Aside from the comparison of neurasthenia with the prodromal 
period, probably the mistaking of syphilis of the central nervous 
system for advanced general paralysis is the most common error in 
diagnosis. The two disorders have so much in common that their 
differentiation is often only possible by prolonged observation through 
the whole course of the disease ; and if the # paretic dementia should 
happen to progress as a simple dementia with none of the character- 
istic episodes, the diagnosis is sometimes quite impossible. The follow- 
ing table will serve to make some of the similar and unlike features of 
the two maladies apparent : 



General Paralysis. 

Paresis of mild degree of cranial nerves 
at times. Slow in onset and trans- 
itory. 

Symptoms of a diffuse general lesion. 

Jerky and ataxic tremor. 

Loss of iris reflex to light, preserva- 
tion of movement of iris in accom- 
modation (Argyll-Robertson pupil); 
extreme miosis. 

Characteristic elisions and reduplications 
of letters, syllables, or words in writ- 
ing. 



Peculiar disorder 
speech.) 



of speech. (Gr. P. 



Headaches vague, transitory, and sel- 
dom distressing. 

No material changes in the fundus. 

Progressive advance of the disease to a 
speedily fatal termination, with a 
possible remission in some instances 
for a brief period. 

Delusions often expansive, sometimes 
depressed, characterized by enor- 
mous exaggeration in either case. 

Affective state often expansive, some- 
times depressed. 

Progressive mental enfeeblement. 

Epileptiform and apoplectiform crises in 
nearly every case, and frequently re- 
peated. 

Antisyphilitic remedies useless. 



Cerebrospinal Syphilis. 

Complete paralysis of one or several 
cranial nerves often. Generally sud- 
den in onset and stable. 

Symptoms of multiple lesions. 

No tremor in syphilis. 

Iris often immobile both to light and in 
accommodation ; extreme miosis 
very infrequent. 

If any change in writing at all, due to 
agraphia or dementia, No resem- 
blance of the changes to those of 
paresis. 

No speech disorder usually, but, if any, 
due to organic aphasias of one kind 
or another. No resemblance to the 
G. P. speech. 

Headaches extremely severe, constant, 
and worse at night. 

Optic neuritis occasionally. 

Irregular advance, with many fluctua- 
tions in intensity and character of 
the symptoms, extending over a 
long period of years, and not neces- 
sarily fatal. 

Delusions rarely present. 



Affective state usually "depressed or apa- 
thetic. 

Incoherence and thought-inhibition. 

Epileptiform and apoplectiform seizures 
uncommon, but if they do occur, are 
generally single, isolated attacks. 

Antisyphilitic remedies of marked ser- 



A gummatous meningitis may, however, present a typical general 
paresis in all its manifestations, and there are cases in which the actual 
lesions of paresis exist side by side with syphilitic cerebral lesions. 

We may have maniacal outbursts in the course of general paresis. 
Indeed, I have seen paresis begin in a number of instances as an 
apparent acute mania. During this maniacal state the chief means of 
differentiation of the two disorders is in the character of the contents of 
the delusions. Both are exalted and expansive and tend to the same 
general exaggeration of feelings of power, strength, intellectual and 



PARALYTIC DEMENTIA. 825 

physical abilities, wealth, social station, etc. But the stupendous ex- 
aggeration in general paresis is never observed in acute mania. This is 
a valuable indication. Naturally, if any of the physical signs of paresis 
are present, the diagnosis is not difficult. 

Epileptic dementia, with its slow speech, mental defect, and epileptic 
seizures, might at times be mistaken for a paralytic dementia, presenting 
chiefly these symptoms. But the history of long years of epilepsy 
preceding the psychic degeneration suffices, as a rule, for the diagnosis. 
It is only when such history is not obtainable that error might arise. 

In paranoia itself, and in paranoia secondary to acute mania or 
melancholia, the expansive or depressed delusions are of a more fixed 
and much less exaggerated nature. A study of the character of the 
delusional contents should make differentiation easy. 

Multiple sclerosis, with its jerky tremor, exaggerated reflexes, and 
mental enfeeblement might at times present a syndrome analogous to 
that of some cases of paralytic dementia. The tremor of multiple 
sclerosis, however, while also jerky and ataxic, is a marked intention 
tremor, exhibiting wider and wider excursions the greater the effort to 
carry on a voluntary movement. The tremor of paresis, on the other 
hand, shows no such increasing exaggeration on voluntary efforts to 
use the muscles. In sclerosis, the head is often involved in the tremor ; 
in paresis, never. Nystagmus, so common in sclerosis, is almost never 
observed in paresis. The dementia of sclerosis, when present, is slight 
and not especially progressive, and there are no expansive or depressed 
delusional episodes, such as characterize paralytic dementia. 

Focal brain-lesions (tumor, hemorrhage, softening, etc.) with de- 
mentia and paralysis may simulate somewhat certain types of general 
paralysis, but the progressive character of the latter disorder, with its 
crises and psychic episodes, should serve to give the condition presented 
definite outline and character. 

Pathological Anatomy. — It is usual to describe the pathological 
condition underlying paralytic dementia in general terms as a diffuse men- 
ingo-en cephalitis. The gross changes observed at autopsy are as follows : 

1. General diminution of weight of the brain. 

2. Increased fluid in the subdural space and in the meshes of the 
arachnoid (external hydrocephalus). 

3. Pachymeningitis hemorrhagica interna, with large, fresh, or old 
hematomata of the dura mater (in about half of the cases). 

4. Chronic leptomeningitis (opacity and thickening, with adhesion 
of the membranes to the cortex). 

5. Narrowing of the cortex, with gaping of the fissures. 

6. Distention of the ventricles with serum and granulated and thick- 
ened ependyma (chronic internal hydrocephalus). 

7. Gray degeneration in the centrum ovale, brain-axis, in various col- 
umns of the spinal cord, and in some of the spinal roots and peripheral 
nerves. 

The microscopical findings of Alzheimer may be summarized briefly 
as follows : 

1. Proliferation of new capillaries and of the endothelial cells and 
adventitia. 



826 MENTAL DISEASES. 

2. Dilatation and infiltration of adventitial lymph-spaces, with 
lymphocytes, mast-cells, and plasma-cells, mostly the latter. 

3. Degenerative changes in the blood-vessels, especially in the 
cortex. 

4. A peculiar cell-form usually present in the cortex (MssPs stab- 
chen cell). 

5. Diverse and wide-spread degeneration of the ganglion-cells, but 
not pathognomonic of paresis. 

6. Arrangement of cell-groups in cortex more or less altered. 

7. Degeneration of axis-cylinders. 

8. Proliferation of glia tissue throughout the cortex, especially about 
the blood-vessels of the outer cortical layers. 

The whole cortex is more or less affected, but often the changes are 
more marked in one area than in another. It is usual to find the 
frontal lobes especially implicated. 

Treatment. — In the majority of cases of general paresis commit- 
ment to an asylum is necessary, owing to the dangers arising from the 
patient's excesses. He may squander his property or scandalize his 
family by his immoral or criminal acts. It is true that cases which 
present merely the dual symptomatology of increasing physical debility 
with progressive mental enfeeblement may be, and often are, treated at 
home. But, on the whole, it is better to act promptly in placing the 
patient in a place of safety. 

The disease being inevitably fatal, there is little to be advised in the 
way of medication, save symptomatic treatment. It is quite proper, 
in cases with a history of syphilis, to try energetic antisyphilitic meas- 
ures — mercurial inunctions and large doses of iodid. Ehrlichias salvar- 
san (" 606 ") has been used in a great many cases, but so far with rather 
harmful than beneficial results. Further experience in this direction may 
show that it has some advantages in the therapy of this disease that are 
as yet not apparent. If, by any possibility, there has been any confu- 
sion of the malady with cerebral syphilis, this will at least serve to 
remove any doubt. The opium treatment is of value in the periods 
of depression, and hyoscin, hyoscyamin, or duboisin (gr. T -i~g- to gr. •£$), 
hypodermatically, in the periods of maniacal excitement. Where epilep- 
tiform seizures are frequent, the bromids are indicated, and in status 
epilepticus chloral and starch-water per rectum (gr. xv to Ij of starch- 
water). Chloral combined with morphin is to be recommended in phases 
marked by hallucinatory excitement. 

Little or nothing is to be expected from the many measures advo- 
cated by various authors : setons and vesicants to the nape of the neck, 
painting the neck with iodin, hydrotherapy, physostigmin, ergotin, and 
trepanation. 

Trephining was resorted to some years ago, but seems to have been 
abandoned as useless. The theory that led to its use was that there 
might be increased intracranial pressure, but this theory has been dis- 
carded for want of evidence. 

When dysphagia is present, the patient may require feeding with the 
tube. In the terminal period of the disorder catheterization and careful 
efforts at preventing bed-sores are required. 



PARANOIA. 827 



CHAPTER X. 
PARANOIA. 

Synonyms. — Chronic delusional insanity ; Progressive systematized insanity ; 
Primare Verriicktheit ; old term, "Monomania." 

Definition. — Paranoia may be defined as a progressive psychosis 
founded on a hereditary basis, characterized by an early hypochon- 
driacal stage, followed by a stage of systematization of delusions of 
persecution which are later transformed into systematized delusions 
of grandeur. Though hallucinations, especially of hearing, are often 
present, the cardinal symptom is the elaborate system of fixed delu- 
sions. 

The hypochondriacal stage is called by Regis " the period of analytic 
concentration " ; the second stage, " the period of delusive explication " ; 
the final stage, " the period of transformation of personality." 

Varieties of Paranoia. — There is one typical form of paranoia 
to which the main portion of this chapter will be devoted, because it is 
the type which will be most readily recognized by the student and 
general practitioner. But there are incomplete or immature forms and 
atypical variations, which the special student of morbid psychology 
learns in the course of time to distinguish. Thus, many of those 
eccentric or queer individuals whom we call " cranks" are rudimentary 
or undeveloped cases of paranoia. Some idea of the varieties of para- 
noia noted by authorities may be gathered from the attempts at classifi- 
cation by different writers. For instance, French and Italian authors 
are inclined to divide paranoia into two great groups — viz., (1) degenera- 
tive, with original and late sub varieties, according to the period of 
life at which the insanity develops ; (2) psychoneurotic, with primary 
and secondary subvarieties, according to whether it develops primarily 
or secondarily to another insanity. 

Ziehen classifies paranoia into two great groups, according to the 
predominance of either delusions or hallucinations — where hallucina- 
tions are the most prominent symptom, he terms the psychosis paranoia 
hallucinatoria ; where delusions are preeminent, he denominates it para- 
noia simplex. Either form may be acute or chronic. Hence he makes 
four chief types : (1) Paranoia hallucinatoria acuta ; (2) Paranoia hal- 
lucinatoria chronica ; (3) Paranoia simplex acuta ; (4) Paranoia sim- 
plex chronica. 

This last form is the name given by Ziehen to the complete typical 
form of paranoia which is described in this chapter, and which he 
describes as having four stages (prodromal, persecutory, expansive, and 
pseudodemented). Ziehen also specifies several varieties of acute hal- 
lucinatory paranoia — viz., the fleeting-idea form, the stuporous, the 
incoherent, the exalted, and the depressive forms. 

Krafft-Ebing makes two great divisions — original paranoia, appear- 



828 MENTAL DISEASES. 

ing in early childhood or before puberty, and acquired (tardive) paranoia, 
appearing between the ages of puberty and sixty years. The latter 
class he subdivides as follows : 

(A) Paranoia persecutoria : (1) the typical form ; (2) subtype 
(paranoia sexualis) ; (3) paranoia querulans. 

(B) Paranoia expansiva : (1) paranoia inventoria and reformatoria ; 
(2) paranoia religiosa ; (3) paranoia erotica. 

Etiology. — Heredity is a more important etiological factor in 
paranoia than in any other form of insanity. Krafft-Ebing states that 
he has never seen a case without hereditary taint. Tanzi and Riva found 
in their cases of paranoia 77 per cent, of heredity and 9.5 per cent, of 
infantile cerebral disorders, while in the remaining 14 per cent, hered- 
itary factors could not be ascertained, but were not, of course, ex- 
cluded. It is more common in females than in males. It affects by 
preference individuals who are even from childhood peculiar, morbid, 
shy, irritable, mistrustful, and misanthropic. It is very common to 
find, in cases of paranoia, some of the various stigmata hereditatis 
described in the chapter on Etiology, such as cranial or facial asymmetry, 
malformations of the ear or palate, etc. 

Symptomatology. — We will examine the symptoms of the different 
stages in the order of their development. In the prodromal period, the 
hypochondriacal stage or period of subjective analysis, as it has been 
variously termed, which may have its conception in early childhood, the 
patient is morbidly shy, peculiar, eccentric, avoids the companionship 
of others, and is prone to withdraw himself into the solitude of his own 
thoughts. The physiological commotion of puberty and adolescence, 
with its inflow into consciousness of innumerable new sensations, its 
flood of new instincts, powers, ambitions, and ideas, tends to intensify 
the morbid proclivities already evident. The patient notes his own 
peculiarities of conduct, and begins to recognize the singularity of many 
of the somesthetic sensations which come to him — sensations which at this 
time might well be considered more or less neurasthenic in character : 
paresthesias of the head, trunk, viscera, and limbs ; pains in various 
parts of the body, tinnitus aurium, sparks and dots before the eyes, and 
the like. The unnaturalness of these sensations leads to his spending 
much time in contemplation of them, so that a hypochondriacal com- 
plexion is given to his thoughts. To these physical sensibilities are 
now added a consciousness of difficulty in the concentration of his 
thoughts ; a difficulty in the proper control of the direction and subject 
matter of his thoughts. He becomes extremely introspective, and, the 
more he studies the somesthetic sensations brought to his attention, the 
more he contemplates the phenomena of the uncontrollability of his 
thoughts, of their rising unbidden from his subliminal consciousness, 
of the unrestrained constellation of his presentations, the more is he 
inclined to search for some cause of his morbid condition. At first, 
like an ordinary hypochondriac, he investigates himself to find a solu- 
tion of the problem, and, failing in that, he extends the region of his 
observation to his environment, seeking there the reason of his strange 
feelings, general disquietude, and morbid stream of thought. He be- 



PARANOIA. 829 

comes wholly preoccupied with himself. He can not employ himself, 
either physically or mentally, as he should. He fails in his duties — 
in everything he undertakes. People seem strange to him in their 
conduct and in what they say. He grows suspicious and distrustful of 
everything and everybody. What is done and said by others appears 
to have some significant relation to himself. People alter in their con- 
duct toward him, look at him curiously, smile sarcastically when he 
passes, wink at or make signs to one another when he is near ; make 
observations among themselves which, overheard by him, are construed 
as having a double meaning, as being derogatory to him, reflecting on 
his character. The more he studies the extraordinary condition of 
aifairs, the more gloomy, solitary, and self-absorbed he becomes. 
Naturally, the growing alteration in himself really does provoke the 
notice of others — a fact which tends to intensify his ever-increasing 
suspiciousness of concealed animosity among those with whom he comes 
in contact. Many things in his past life rise up in his memory to find 
a new interpretation in the light of his present general distrust. His 
physical sensations have become more marked, have taken on a new 
character, have altered from paresthesias to illusions, and even hallucina- 
tions, of general or special sensibility. He feels peculiar general sensa- 
tions, shooting pains, sudden prickings in his skin. Unusual and 
unpleasant odors or tastes harass him. Extraordinary sensations flow 
into consciousness from his genital organs. Much more serious and 
remarkable, however, are the peculiar changes in his auditory percep- 
tions. At first these are usually confused noises, or roaring and 
tinkling sounds, with the gradual perversion of sounds and words 
heard into illusions colored by the suspicious contents of the patient's 
consciousness ; later, actual hallucinations of hearing, which become a 
fixed and permanent feature of his malady. 

The patient now enters into the second or persecutory period of 
paranoia, the period of delusional explication of his troubles. He has 
arrived at what he conceives to be a logical result of his reasonings, a 
rational explanation of the distress and affliction he has undergone. 
Everything he has suffered has been due to the machinations of un- 
known enemies. The delusions of persecution are at first somewhat con- 
fused in character. No particular individual or group of individuals is 
thus far responsible for the inflictions. It is simply some unknown 
persons who take pains to manifest ill-will or malevolence toward him. 
" They " talk against him, call him names, attempt to poison him with 
gases or by tampering with his food, and try to injure him with electric 
shocks or by throwing corrosive substances at him. Since wherever the 
patient may be, wherever he may go, the voices, shocks, poisons, etc., 
seem to pursue him, he comes to think that no single person could 
manage so vast a conspiracy. It must be some large aggregation of 
persons who are concerned in the effort to humiliate, cripple, or destroy 
him ; an aggregation bound together by ties of secrecy, and able to per- 
meate all classes of society. What could such body be but a secret 
society, an order of Masons or Odd Fellows ; some religious or political 
brotherhood — the Jesuits, Catholics, Protestants, anarchists, or police. 



830 



MENTAL DISEASES. 



Perhaps some one individual is at the head of the band of plotters, some 
arch-conspirator, but the work is done by innumerable aides, who 
employ all manner of means and apparatus to accomplish his ruin. 
This system of persecutory ideas is built up in the most elaborate way, 
and the more educated the individual suffering from paranoia, the more 
wonderful the organization and adjustment of the various parts of the 
delusional system. The persecutory delusions of other forms of psy- 
choses, such as toxic insanity, senile dementia, and melancholia, may 
have a certain interest and fixity, but those of the paranoiac are woven 
together like a romance. The relation of the former to the latter is that 
of the brief sketch to the serial novel. The telephone, the phonograph, 
telepathy, hypnotism, and other and more mysterious apparatus and 

phenomena are brought into service 
by the relentless league. I do not 
know the origin of Du Maimer's 
conception of his novel, " Peter 
Ibbetsen," but I suspect that many 
of its unique features, especially 
that of " dreaming true/' were sug- 
gested by conversations with some 
well-educated paranoiac in a lunatic 
asylum. 

Many patients seek in a most 
elaborate way to explain one pecu- 
liarity of their auditory hallucina- 
tions — viz., the fact that their 
thoughts are read off by the voice 
or voices simultaneously with the 
appearance of the thoughts in con- 
sciousness. This adds naturally a 
new terror to the persecution, for 
the ability of the conspirators to 
read off and taunt the patient with 
his own most secret thoughts is 
a particularly refined species of 
deviltry, as well as evidence of the 
extraordinary psychological power 
of his tormentors. The voice which speaks his thoughts, or answers 
his thoughts before he can himself utter them, may be referred to the 
external world or to some part of his own body. This phenomenon 
has been variously termed echoing of the thoughts, motor representation 
of articulation, and verbal psychomotor hallucination. It depends upon 
the close relation existing from earliest infancy between the auditory 
word-center and the motor speech-center. Any irritation of this audi- 
tory area is immediately, synchronously, irradiated to the motor speech- 
center. However slight this stimulation of the speech-muscles, recur- 
rent sensations of movement in them are carried back to the brain, 
giving rise to the hallucinations of internal hearing. 

The patient is driven by his delusions to make complaints to the 




Fig. olo. — Young paranoiac with homicidal 
tendencies at period of passing from persecutory 
into grandiose stage (Dr. Atwood). 



PARANOIA. 



831 



police, to judges, or to the governor of the State, the President, or other 
government or judicial authorities. Not infrequently he attempts, him- 
self, to wreak vengeance upon one or more of his imaginary enemies. 
Attempts at homicide are, therefore, common in these cases. The 
writer had in his charge at the Poughkeepsie Asylum, for some years, 
Ernest Duborgue, a persecutory paranoiac, who, many years ago, ran 
through Fourteenth Street, New York, stabbing women right and left 
with a pair of compasses. More often they seek to escape from their 
enemies by constant change of residence. 

The third stage, the expansive period, or the period of transforma- 
tion of personality, is often induced by the patient's attempt at a logical 
explanation of the cause of the persecution. Since he has so many 
enemies, and every man's hand is against him, it must be due to his 
importance. He either resembles some distinguished personage or he 
is of royal or god-like descent. The 
transformation may be suddenly induced 
by a hallucination revealing to him his 
high estate. The contents of these 
delusions of grandeur may be religious, 
political, erotic, jealous, and so on. 
For instance, the delusion of being 
a prophet or a second Messiah is 
very common (paranoia religiosa). The 
delusion of being a great discoverer 
or inventor is frequently met with 
(paranoia inventoria). Another com- 
mon delusion is that of being a great 
social reformer (paranoia reformatoria). 
A peculiar form is paranoia erotica, in 
which a person imagines him- or herself 
to be beloved by some one of superior 
station. It is a romantic, platonic love 
in which the patient indulges. He 
has communications with the object of 
his delusions, imaginary conversations, 
through the medium of hallucinations. A good example of this form was 
that of Dougherty, who followed Mary Anderson all over the country, 
and was finally sent to an asylum because of his threats to kill any one 
who interfered with his attempts to gain a personal interview with the 
famous actress. Measurements which I made of his head showed a 
pathological excess in the height of the skull. 1 After his commitment 
to an asylum he shot one of the physicians who had him in charge. 
Another interesting variety of paranoia is that observed in the litiga- 
tionists (paranoia querulans), who occasionally distinguish themselves by 
their lifelong involvement in legal processes (due to an overwhelming 
egotism, which leads to a continual zealous effort to set themselves right, 
despite the advice of friends, and the wasting of their property, after the 

1 "Familiar Forms of Nervous Disease," by M. Allen Starr, New York, 1890. 
Article on ' ' Paranoia, " by F. Peterson, page 299. 




Fig. 314. — Erotic paranoia. " Mary Ander- 
son's lover " (see text). 



832 MENTAL DISEASES. 

loss of some possibly trivial lawsuit). Pretenders to thrones, self-styled 
kings, presidents, princes, and so on, are often noted among paranoiacs 
who have reached this third stage of evolution. Quite commonly per- 
secutory ideas still remain in the minds of these patients in association 
with the delusions of grandeur. 

Each of these periods of development may last for several years, 
the disorder may undergo arrest at any period, and there may be varia- 
tions in the degree of development of any stage ; so that we constantly 
meet with atypical forms of paranoia. An excellent condition of 
memory, judgment, and intellect in all other directions save in those 
related to the single cluster of delusions may coexist. Years ago these 
cases were designated as monomania, because of the apparent lucidity 
of the patient outside of the limited number of fixed ideas. Many 
paranoiacs have distinguished themselves in sacred and profane history, 
and even in literature. There have been many of these false prophets 
who have come to herald a new religion — Mahomet, Swedenborg, 
Johanna Southcott, John of Leyden, John Thorn of Canterbury, and some 
say Jeanne d'Arc. We have had them even in the United States within 
a few years — the healers exploited by the press. Among political re- 
formers we had John Brown and Guiteau. A famous paranoiac immor- 
talized himself in his autobiography — Benvenuto Cellini. 

I have in my possession a beautifully written manuscript — the 
autobiography of a paranoiac. He was so dangerously insane that he 
spent much of his life in the asylum in which he wrote this valua- 
ble work. x The volume, bound by himself, is entitled " The Piling 
of Tophet," which is significant of the sufferings he had undergone in 
his unhappy life. I believe no better idea of the typical form of para- 
noia can be obtained than by a careful reading of the history of this 
case as given by the person himself. It is a graphic picture of the 
steady evolution of the malady — a remarkable self-dissection of the 
soul's anatomy. Before presenting the extracts from his autobiography, 
I shall make a few transcripts from his asylum history. 

He was thirty years of age at the time of admission ; single ; a farm- 
laborer by occupation. He was not a church-member, had a common- 
school education, and was a native of the United States. Hereditary 
predisposition was not acknowledged. His mother, who accompanied 
him to the hospital, stated that he had always been delicate in his physi- 
cal constitution, and given to despondency. Since the age of twenty 
he had done little or nothing, because of ill health. A year previous 
to his commitment to the hospital as a lunatic he shot himself in the 
forehead in an ineffectual attempt at suicide. Later, he developed de- 
lusions that the people of the village were acting upon him by mag- 
netism, spoke disparagingly of him, and were conspirators against his 
peace. During the whole of his sojourn in the hospital he had hallu- 
cinations of hearing, and in the earlier period of his stay had delusions 
of persecution. Toward the end of his seven years of hospital life he 
gradually developed, in addition, delusions of grandeur. Although he 

1 "Extracts from the Autobiography of a Paranoiac," edited by Frederick Peter- 
son, "Amer. Jour, of Psychology," January, 1889. 



PARANOIA. 833 

had occasional lapses of self-control, manifested by the breaking of 
window-glass or the tearing of clothing, he was for the greater portion 
of the time sufficiently self-possessed to restrain whatever violent or 
destructive inclinations he may have had, and was permitted to go out 
alone upon the large grounds of the asylum whenever he wished, and 
to wander about the woods at will. 

It was during the last two years of his stay at the asylum, while 
still the victim of constant auditory hallucinations, and of mingled 
delusions of persecution, unseen agency, and grandeur, that he wrote 
the volume of four hundred manuscript pages with the extraordinary 
title of " The Piling of Tophet," this title being founded upon Isaiah 
xxx, 33. The book itself is a deeper history of his life and mental 
evolution than any but himself could furnish. It is remarkable for its 
excellent literary style and for its keen reasoning and psychological 
analysis of his own disordered mind. In it he dissects his hallucina- 
tions and delusions like a skilled anatomist. It is as fascinating as a 
novel. Every page has its value as an index of the condition of his 
mind from childhood to the last years of his confinement in the asylum ; 
and the story is told with a directness and simplicity that marks truth 
upon every statement and lends it such charm as pertains to all works 
which portray life with the utmost fidelity. In his preface and intro- 
duction he makes a diagnosis of his own disease. 

Our author, as has already been stated, was not a church-member, 
and in his book he describes his early religious life and his subsequent 
beliefs as they developed. His father was a Universalist and his 
mother a non-professor of religion, although she did attend the Meth- 
odist church. During his boyhood he attended the Sunday-school 
regularly, and at one time the Episcopal church ; but his attendance 
upon divine service ceased in early youth. Both parents were honest, 
conscientious, and highly respected in the community. They were first 
cousins. The mother was healthy in mind and body, but the father is 
reported to have been exceedingly eccentric, possibly insane. From 
what I subsequently learned regarding him, he also was something of a 
paranoiac. They strove to bring up their children carefully and to 
educate them as well as possible. 

His father died when the patient was twelve years of age. Up to 
the age of thirteen he attended a country school both winter and summer, 
but after that his farm-work permitted him only winter schooling. Still, 
he evidently had unusual talents and aptitudes, and we find him later 
studying by himself, in the original, many of the classic Latin authors ; 
and among his favorite companions were the works of Boethius, Lucre- 
tius, Josephus, and the Bible. His literary style and modes of thought 
are in themselves an evidence of more than ordinary attainments in 
rhetoric, philosophy, and logic. 

The matter of heredity in his case was not sifted thoroughly upon 
his admission to the asylum, nor have I since been able to gather much 
material relative to this factor in his evolution. But one important 
element of this nature is described in his book — an element not only 
hereditary in its character, but for a long time part of his environment, 



834 MENTAL DISEASES. 

and undoubtedly an influence modifying his mental condition both 
before and after his birth. I allude to a great-uncle, a brother of his 
grandmother on his mother's side, who was himself a paranoiac, and who 
lived upon the farm in intimate companionship with our patient until 
the latter was twenty-three years old. 

As we read on we see, from the author's account of himself, how 
heredity and environment gradually molded his physical and mental 
characters. A shy, timid, delicate child ; clever intellectually ; given to 
oddities of speech and conduct ; inclined to solitary musing, rarely shar- 
ing the sports or games of other boys — in him were slowly evolved 
marked eccentricity of demeanor, a disposition to shun his fellows, a 
misinterpretation of their looks and actions as regarded himself, a mor- 
bid egotism, a consciousness of a gulf between himself and ordinary 
men, with deep depression, outbursts of passion, an inclination to 
homicide restrained but feebly by his weakened will, and delusions of 
persecution. No doubt the derogatory remarks he fancied expressed 
about him in the stores were the first harbingers of auditory hallucina- 
tions. Later, he had murder in his thoughts, through the morbid hu- 
miliation he felt at the imaginary insults from others. No doubt, as 
his conduct grew more and more strange, he did attract attention among 
his fellow-men, and this, unfortunately, would but feed the flame of his 
pathological self-consciousness. 

We follow his history from infancy through childhood and youth to 
manhood, and observe how, slowly but surely, the hereditary seed sown 
in degenerative soil took root and flourished. His peculiar auditory 
acuteness, with his morbid shyness, soon gave rise to illusions of hear- 
ing, and these again were transformed into hallucinations, as is evident 
if the thread of the narrative is carefully followed. The curious foun- 
dation of his hallucinations he well illustrates and understands. An 
idea arises in his own mind of what people would say in discussing 
him, and immediately consciousness in the auditory area projects the 
idea in spoken words into the environment. He noted this peculiarity 
of his own thoughts being repeated to him by the voices about him, yet 
he could not correct the delusions to which they gave origin, but inter- 
preted the matter with the reason and judgment of an insane mind. 
He naturally had the delusion, founded upon his hallucinations, that 
people were persecuting him, but upon this now grew another delusion. 
He began to believe that they could read and repeat his thoughts ; that 
there was some magnetic means by which his tormentors could draw off 
his thoughts ; that other wills could act upon his body, dominating his 
own will and causing him to do things he had no desire or intention of 
doing. 

It was about this time that he was removed to the asylum. Several 
chapters of his book are devoted to a description of his life there, his 
religious beliefs, illusions, and hallucinations. A short time previous 
to his departure for the asylum he began to read much in the Bible, 
and, as he says, noted passages which seemed to have a special bearing 
as regarded himself. There were several coincidences of this kind, and 
he looked upon them at first as merely coincidences, but in time the 



PARANOIA. 835 

resemblance became so strongly marked, to his disordered intelligence, 
that he came to look upon whole chapters of the Bible as referring to 
himself. From this the step was not a great one to the delusion of 
being a prophet. In reading we find that our author had several in- 
centives for writing this book. It contains the autobiography of a new 
prophet, as well as the revelation of a new religion. From his stand- 
point, as a man in whose destiny are wrapped up the destinies of the 
world, he tells posterity of the tortures and trials he has passed through 
as an atonement for the sins of the earth ; how he was mocked and 
scoffed at, his brain acted upon by magnetic agency, and himself im- 
prisoned in a lunatic asylum for years. Hence the title of his book, 
" The Piling of Tophet." But behind this insane egotism there shines 
at times some faint glimmer of the truth, so that he frequently speaks of 
himself in the terms used by his fellows, as insane, a lunatic, a mono- 
maniac, as having hallucinations ; and he thinks the opinions of his 
friends, relatives, and physicians of sufficient worth to merit considerable 
argument in his book. He knows what insanity is ; he recognizes it in 
his asylum associates. He could at times " see the man he ought to 
have become rising up like a shadowy phantom in judgment on the 
wreck he really was." But this occasional consciousness of their dis- 
ordered mental condition is by no means infrequent in the insane. 

Shortly after writing his autobiography he was removed to a county 
asylum, where he remained, without change in his mental condition, for 
several years, when his friends took him out to live with them. He died 
a religious paranoiac in 1886. He did not become completely imbecile, 
as such cases often do ; nor did he write any further articles, so far as I 
am aware. Doubtless the indifference with which the world received 
the propagandism of the new prophet caused his philosophical with- 
drawal from active warfare in the fields of reform and theology. 

In the preface he defines the scope of the book as follows : 

" This work is given to the public as a lunatic's defense of his posi- 
tion. Every effort I have made hitherto to come to an understanding 
with my fellow-men, on things which I see to proceed from them, and 
which give my life its whole shape, has drawn out nothing more than 
blank denials of all knowledge of the things I spoke of. Now, it is im- 
possible for me to reduce my thoughts to the bounds which others have 
been willing to concede. The object of this little autobiography is to 
show the form and consistency of the thought that is in my mind. 

' ' I present rny evidence to the tribunals of last resort, the public and 
the press, and ask them to try the case and render their verdict. Have 
I a right to my thought, or have I not ? If not, where am I deceived ? 
If I have, why is not mine the true thought for all men ? ' ' 

A paragraph from the introduction further reveals the object of his 
confessions : 

' ' A person is supposed to have a reason for what he does, and I 
might consider it incumbent upon me to tell the motives which actuate 
me in thus entering upon the work of the scribe under circumstances so 
peculiar. Is there anything I have to tell that might not as well and 



836 



MENTAL DISEASES. 



more safely be left untold ? It is a question which I do not have to 
consider and decide to-day, for I have been long inspired with the con- 
viction, the consciousness, that I have something to tell that it would be 
worth the world's while to hear." 

In another introductory paragraph he makes an excellent diagnosis 
of his mental infirmity. Addressing his reader, he says : 

' ' I did not tell you that I am a patient in an asylum. I am to take 
it for granted at the outset that my prospective reader knows nothing of 
my character, condition, or circumstances beyond what I tell him. I 
am here as an insane patient. I have been here over five years. . . . 
Being an insane man, it will be nothing unexpected that I should, in 
giving these reports of my fortunes, narrate incidents and particulars 
partaking more or less of the marvelous or preternatural. I am not 
only a lunatic, but one of the class of lunatics having a controversy with 
the world in general; in other words, possessed with a monomania, or 
crazy one-sidedly or on a single subject." 

In the hospital record presented above, nothing is adduced as to 
heredity in this case, and but little stated concerning his mental condi- 
tion in early youth. These deficiencies are, to a great extent, supplied 
in the autobiography. I shall permit our author first to describe his 
appearance in this world, in a cyanotic condition, and the characteristics 
of his childhood and early youth, and subsequently the hereditary 
influence in his destiny : 

"It is said that I was entirely black when I was ushered into the 
world, and that for I forget how long a period of time I did nothing 
but give vent to heart-saddening wails. Was I lamenting the gift of 
light, on this morning of what was to become a woe-burdened existence ? 

" I was a weakly infant. I came near dying of the whooping-cough, 
and it was always asserted, by those who knew, that I owed my life to 
the untiring exertions of a poor woman who lived a neighbor, who 
busied herself all night with me, dipping me at intervals into a tub of 
warm water. My half-sister had it at the same time and died. 

' ' It will be of use to give an idea of my nature and disposition in 
my tender years. I was always a shy, retiring child; not disposed to 
make free with strangers; not much given to prattle — in fact, one of the 
sad and silent sort from the first. I can remember some peculiar sensa- 
tions which used to weigh on my mind, which go to show that the 
foundation of my mind-life was but imperfect from the first. I used to 
be troubled with very strange feelings when I was waking out of sleep, 
especially if I had been taking a nap in the day-time. It used to seem 
to me that I was floating in the air, and I often thought to myself : 
' Why, how queer I have been feeling! ' It was as if I filled the whole 
room, way up to the ceiling. I was told by others that I sometimes 
raised myself up in bed after getting to sleep and made an outcry, ' Oh, 
don't! Oh, don't! ' seeming to be in great distress; but the strange part 
of it is that I could remember nothing about it. I do not think that I 
ever remembered even their waking me, or finding them at my bedside. 
I only had their word for it next day. 

"As far as I can go back, I remember having at times, but not fre- 



PARANOIA. 837 

quently, impressions which must be identical with what I have lately 
heard others speak of as ' double memory. ' The feeling would all at 
once creep over me that the very thing I was present with, my ideas and 
perceptions at that time, had happened to me once before in just the 
same sequence and arrangement. I have heard this explained as due 
to a lack of simultaneity in the action of the two lobes of the brain, the 
tardy one remembering what had already passed through the other. 
My own theory was different, leaving the organ acting out of con- 
sideration. I only went so far as to look at it as a mistaken quality 
in the perception — an erroneous attaching of the nature of the act of 
remembering to what was really the act of thinking in the present. 

' ' I was very early in life an observer of ni}^ own mental peculiarities, 
to a degree which I think must be a very rare exception. I often used 
to be sensible of an unsatisfactoriness in my consciousness of what sur- 
rounded me. I used to ask myself, ' "Why is it that while I see and 
hear and feel everything perfectly, it nevertheless does not seem real to 
me ? It is as if I were in danger of forgetting myself and the place 
where I am! ' I often wondered even how I kept the run of things as 
well as I did. I always found myself holding on to the orderly and 
proper connection of my acts, and yet from my feelings I could not have 
answered for my doing so. I can remember sitting at my desk in 
school, when a small boy, and dwelling with melancholy on this dim- 
ness in my perception of existence, and wondering how it was with 
others in this respect. I wondered to myself if life, as ordinarily be- 
stowed, included this deficiency. 

' ' I showed in my tastes and behavior a harmony with the internal 
composition of my mind. I was never given to the active sports which 
the common run of boys take so much delight in. 

" The simple fact is that I had a languid nervous development, and 
from the necessity of my organization could not have much capacity or 
relish for sports of agility. 

" If I could compound a boy of my own I should try to improve on 
the model I remember to have exhibited in myself. 

" It is not true that I was regarded or treated as strange or deficient 
in my wits. Such an idea would look misplaced to those who knew 
me and consorted with me in those days. These differences are perhaps 
more evident to myself than they ever were to the greater part of my 
acquaintances. I brooded on this side of my character at a later period, 
and I no doubt remain liable to give greater prominence to disparaging 
traits than some impartial observers would justify me in doing. 

' ' As a general rule, my harmless and peaceable disposition kept me 
out of squabbles Avith my schoolmates. If I was approached in an 
aggressive way, I met it with absolute non-resistance, which in my case 
had the disarming effect which is attributed to it by pious moralists. 

" If we change the scene from the playground to the schoolroom, we 
shall find that I attained a distinction of my own, apart from the 
average, and more to my advantage there. I was always a favorite with 
my teachers. I never gave them any trouble, and took to my studies 
with a willing relish that could not but be pleasing to them. I learned 
to read before I went to school; in fact, like an old asylum acquaint- 
ance, Mr. M.j inventor and infidel monomaniac, I can almost say that 
I can't remember when I could not read. 

' ' I was frequently singled out for complimentary remarks on my 



g38 MENTAL DISEASES. 

proficiency in my studies. I gave evidence of some talents of a higher 
kind — could draw, for instance, better than any boy in the school. 

' ' One of the most marked weaknesses of my character, as a child, 
was my susceptibility to being teased. 

"After having pondered some on the traits of the human animal in 
this particular, I have come to the conclusion that there is no further 
explanation needed than that the impression made on the teaser by the 
teasable is such as to naturally prompt the acts constituting the teasing, 
as the sense of burning makes us shrink, and an aroma suggestive of a 
fine flavor tempts us to bite. I feel convinced that the liability to be 
teased rests on a principle that has a mighty influence in the motions of 
the soul of humanity. 

' ' My misdeeds, as a child, were rarely prompted by a love of 
mischief or the result of headlong thoughtlessness. 

' ' I had a well-defined idea of the nature of sin, and I used fre- 
quently at night to recall the events of the day, and reflect on instances 
in which I had transgressed and given way to ill-humor, and form reso- 
lutions to try and do better. From some of the most flagrant of the 
sins and improprieties to which small and larger boys are prone I was 
entirely free. 

' ' My early training can not be said to have been a predominantly 
religious one. My mind was neither imbued with ineradicable preju- 
dices nor prepared for reaction to the other extreme by excessively rigid 
sectarian drilling and formalism. 

' ' I worked steadily upon the farm, though with moderation, at 
such kinds of work as I seemed to be equal to. The heavier kinds of 
work, such as plowing and wagoning, as also the marketing of the 
produce, were attended to by my great-uncle. 

"It is a somewhat delicate subject to manage to my satisfaction 
this that I am about to enter upon, but it demands candid and impar- 
tial treatment, because the events that followed in later years can not 
be rightly understood without it. It is impossible for me to give a 
veracious sketch of my soul-life during this period without dwelling 
quite minutely on the characteristics of my great -uncle. He was a man 
who had roughed it a good deal in the world, had been at one time in 
his life a live-oaker in Florida. How his temper and disposition may 
have been at an earlier period I can not say — I only remember him as 
a man possessed of the belief that a certain young man living on an 
adjoining farm had the power to torture him at his pleasure, both by 
bothering his brains and inflicting physical pain; which power he made 
use of to such good effect that the poor victim was almost constantly 
kept busy holding him at bay by means of cursings of the most fierce 
and vigorous description. While at work with the horses in the fields, 
and when driving, he would intermix his commands to the animals 
with savage execrations of the troubler of his peace. The unfortunate 
man was troubled, at certain seasons of the year especially, with sore 
feet, and at such times his imprecations against the offender would 
fairly rise to yells, and were almost blood-curdling in their intense 
ferocity. Thus it went on day and night. He slept in a small room in 
one of the outbuildings, and often he could be heard at a great distance 
off shouting out threats, sometimes throwing boots or boot-jacks against 
the boarded side of the building where he lodged to put in the inter- 
jection points. 



PARANOIA. 839 

" It may be imagined that a boy of a reserved and sensitive disposi- 
tion, as I was, could not assimilate very well with such a character as 
this. I was always distant in my intercourse with him, and a feeling 
of aversion for his habits of savagery led me to avoid coming in contact 
with him more than was rendered necessary by our joint labors on the 
farm. 

"As the years passed on and I continued to live in the presence 
of my uncle's fierce demonstrations of hostility against the invisible 
destroyer of his comfort, my tolerance for his conduct insensibly gave 
way. I had now reached the age of eighteen or nineteen; was a tall, 
slender youth, not strong either in nerve or muscle. 

"The exhibition of his ruling passion called up more and more 
determined feelings of antagonism in my breast. 

' ' Before I knew it I had gone a criminal length in my resentful 
feeling. I came at last to feel that a person of such a thoroughly 
savage character did not deserve more indulgence than a mad dog. My 
position from that time was one of contingent murder. Alas ! that I 
should have been content to let such a state of things last a single day. 
The frightful danger of my situation ought to have been sufficient to 
spur me to sacrifice everything to escape from it. But I was in chains, 
the chains of apathy, impotence, and incapacity, and I could only stay 
where I was and fume against the object of my detestation. 

' ' I must always regard it as one of the most unfortunate things in 
my unfortunate career that I should have been placed in contact with 
this much to be commiserated sufferer at such a time of life. It was 
not the man himself that I hated. When my judgment could act with- 
out impediment, I saw that his unpleasant behavior was entirely the 
phenomena presented by his never-ending war against what was, in his 
eyes, the most wicked and cruel of persecutions. I could then pity him 
and dismiss all rancorous thoughts. ' ' 

This antipathy led to a change in the residence of our author. He 
felt that he must be separated from his uncle, and, accordingly, he re- 
moved to a town at some distance from the farm. It is curious that 
he never speaks of his uncle as insane, and it is probable that both his 
mother and himself and other relatives regarded his persecutory delu- 
sions as merely evidence of eccentricity. Soon after removing to town 
he had some pulmonary difficulty, and he speaks at some length of this 
as follows : 

" In the depressed state of my nerves I imagined myself much worse 
than I really was, and, like many others in the same condition, I felt 
as if I was liable to sink away and die at any time. My disease was 
accompanied with periodical accesses of fever, and in the fictitious 
strength of excitement given by this my mind seemed to gain an ab- 
normal activity. It was at this time that I first received a revelation on 
the mysteries of the human soul that had an all-dominant effect on 
my destinies and the turn of my thoughts ever after. ... I now 
learned what had always been to me a hidden mystery — what was the 
meaning of strength of will and strength of intellect, Before, I had ever 
lived enshrouded in mists and clouds. In that transitory strength given 
by the fever coursing through my veins, I now saw the man I ought 
to have become rising up like a shadowy phantom in judgment on the 



840 MENTAL DISEASES. 

wreck which I really was . . . My agitation was so great that my 
mother and the neighbors seemed to fear that I was going crazy. I 
felt that I had been crazy for a long while and had just recovered reason. 
It was a fact. But I was constrained to lock up my remorseful agony 
in my own breast, ' ' 

We have seen that our patient was throughout his early youth 
morbidly subjective, and his hypochondriasis increased with years. He 
had now attained the age of twenty-three ; we shall let him describe his 
mental condition and habits of life at this time. In this description we 
shall see the gradual growth of persecutory ideas upon a favorable soil : 

"My strength and endurance were not sufficient for manual labor, 
and I did not feel confidence enough in the clearness and energy of my 
mind to justify me in making application for any post where head-work 
would have been demanded, or for which ready presence of mind or a 
good address would have been required. But it was the unpleasantness 
felt on contact with my fellow-men that operated more strongly than 
anything else in binding me down to the course of life to which I de- 
voted myself. I felt my deficiencies most keenly every time I met a 

human being face to face I could not do otherwise than 

shun what was so galling to my sensibility, while appearing to conduce 

to no desirable end But I am going to show that I still 

remained exposed to very great dangers, and it is as true as it was 
before that I shunned the only means of averting the calamities threat- 
ening me, no doubt of necessity at this stage, and in obedience to the 
eternal decree that every tree shall spread out and develop in accord- 
ance with the qualities given to it ' before it was in the ground. ' I did 
not like the constraint imposed upon me by the presence of man. I did 
like the freedom of solitude. I strongly disliked many things I noticed 
in the manner and words of some I met, and there was nothing to pre- 
vent this dislike from occasionally being absorbed into my solitary 
musings, to find its final resolution in the passion of indignation in its 
various degrees of intensity as the case might be. I have spoken before 
of my defective means of defense against ' teasing ' or mocking for the 
purpose of troubling. I was always terribly alert and sensitive to all 
kinds of ( snubs ' and sneers, and oblique remarks in general, on their 

proficiency in which some people pride themselves so much 

I was also disagreeably impressed by the ways of some who showed a 
disposition to turn their attention to myself, instead of confining them- 
selves to the subject I was presenting to them. 

' ' I was being carried into a state of secret enmity to mankind in 
general by the prevailing tenor of my brooding meditations, and there 
was no corrective present. 

"But all received a hue from a yearning for what was worthy 
in life, paired with a mournful sense of its hopeless absence. What- 
ever wrong turns I may in my weakness have been betrayed into, it is 
impossible that I should look upon my then existing frame of mind 
as a whole with repentant feelings. As well condemn righteousness 
and holiness itself ! 

' ' When I admit that I occasionally was overcome with an irruption 
of hard feelings toward wrong-doing man, it will, of course, not be 
understood that I was habitually morose and spiteful in temper. 



PARANOIA. 841 

Nothing could be further from the truth. What commotion there was 
was mostly internal, rarely reaching the surface in visible ebullitions. 
I occupied myself with the trifling labors of my garden, 
dwelling with interest and pleasure on the progress of my crops and 
flowers, and every now and then took a ramble over to the woods lying 
to the south, which were a favorite place of resort to me all the while I 
lived there. There I botanized and moralized, explored the recesses of 
the woods, enjoyed the calm quiet of nature, and groaned over my 
hapless condition, wondering what it was to come to. 

' ' There were some little things that happened to me the first year 
after I left the farm which became, as it were, a kind of sample of what 
I must continue to expect, and the memory of which had more influ- 
ence over my action in after time than I was aware of myself, no 

doubt When I was around the city, thinking I might get 

employment I called on one of my old acquaintances, who was then in 
a store. I talked with him a few minutes at that time. I called again 
a short time after, when I was told by the proprietor that the gentle- 
man I had called to see was not in. There were a number of men 
present in the store, — salesmen, — and it became apparent to me that they 
were trying to exhibit an offensive demeanor toward me, or perhaps it 
would be as true to say that they were moved to make a derisive de- 
monstration against me. At all events, all, with perhaps the excep- 
tion of the proprietor, stood with contortions of countenance, which 

was perhaps laughter, until I retired I found it hard to 

consign this to forgetfulness. At first it lay dormant, but it would 
come up, and I must confess I had hard feelings, even revengeful feel- 
ings, toward the actors. Another thing happened the same fall. I 
went to a store, and, standing at the counter, was noticed by one of the 
clerks, — an Irishman, — who came to me and said, 'I always wait on the 
little boys first,' and, as I took no notice of the remark, seemed so de- 
termined his words should not be lost on me that he repeated them, 
with the addition, 'like you.' As before, it produced no immediate 
effect, but it afterward rose and rankled in my memory, and I was not 
able to keep clear of imagining vindictive things. In fact, to tell the 
truth, in both cases I felt that blood would have been sweet to me. 
My mode of thinking on these incidents no doubt had in it 

much of the character of insanity The effect was that I 

got settled down into the fixed idea that contact with the thoughtless, 
evil world, in my state of body and mind, would impose upon me the 

necessity of committing crime in vindication of my honor 

I let these bloody memories tinge my whole mind, and all its anticipa- 
tions and resolutions for the future 'I see, ' I said to my- 
self, in substance, ' that these galling collisions are the natural penalties 
of being imperfect. ' 

"It maybe as well, for the prevention of misconceptions, to say 
that I never took one step toward putting any design thence arising 
into execution. I had no designs. I never armed myself, or, in fact, 
went any further than to rehearse the drama of revenge in my own 
mind. The pistol I bought was one which I would not have trusted for 
a moment to carry for the purpose of self-defense Never- 
theless, the events on the farm show that my wickedness was not 
altogether of a mimic kind, and I will not attempt to escape righteous 
judgment. 



842 MENTAL DISEASES. 

1 ' I used to make many resolutions about regularity in habits of eat- 
ing, which I found myself powerless to keep. A sense of depression 
and vacuity would come over me, aggravated by my solitary, monoto- 
nous life, I presume, and often by an obstructed state of the alimentary 

organs It is a common feature in insanity or semi-insanity 

left to itself, I think. I also exerted my brain to the extent of abuse, 
I know, in the way of study. ... I used to study Latin for a 

pastime, and often kept cudgeling my brains over Cicero and Csesar 
until the top of my head was very sore. This solitary immersing of 
an enfeebled mind in study, with obliviousness to myself and all sur- 
roundings, was, no doubt, a help toward the grand consummation that 

took place in the fullness of things I suffered a good deal 

from bodily ailments. My liver seemed to be thoroughly out of order 
and torpid. I had a feeling of hardness and inflammation in my sides 
regularly, a certain length of time after meals ; digestion was bad, 
appetite irregular — in fact, every sign of a deadlock in the vital func- 
tions. ' ' 

His mother and he removed to another village in 1871, when he 
was twenty-eight years of age, by which time there was but little 
question of his insanity, even among his relatives. I let him take the 
thread of the story again at this epoch : 

" When my mother was making preparations for moving she asked 
me to help in packing up some chairs. I made an effort to apply my- 
self to the task, but suddenly found myself overcome by my feelings, 
and before I knew what I was about I had shivered one of the chairs to 
fragments. A most unpromising omen ! The fact is that I was, and 
had been for some time, in a state which any physician, knowing the 
facts, would have pronounced to be unmistakable insanity. But I 
had different ideas about what constituted insanity, and often thought 
to myself that if I did get put into an asylum, as had been threatened, 
they would not keep me, because they would see that I was perfectly 
rational. I have learned more about the subject since. 

• ' Things of the kind I have told of had happened to me before, at 
uncertain intervals, during several years, an obstructed state of the 
bowels bringing on a turn. I would get into such a condition of exag- 
gerated discomfort as to lose for a moment, or sometimes quite a spell, 
my control over my actions, and act very strangely. Sometimes I 
dashed down an article I happened to have in my hands, or demolished 
the first thing that came to hand; sometimes I gave vent to my feelings 
by grating my teeth, ' clawing ' my face, and going through strange 
grimaces and agonizing contortions. My face seemed to me to be par- 
alyzed when I had such turns, as if lifeless. The worst thing I ever 
did was when I flew at my mother in a sudden access of frenzy one day, 
when she had wrought upon my feelings by talking to me irritatingly, 
and bit out a mouthful of her hair. . . . When I was committed 
to the asylum, at a later day, it was reported as one of my symptoms 
that I had delusions about my mother being my enemy, etc. , but noth- 
ing could be further from the truth. ... I often grieved in secret 
over my inability to be a stay and protection to her, bereft as she was 
of all other support, but all in vain. 

1 ' In my new home I was in one of a row of houses, with strangers 



PARANOIA. g43 

living near on both sides, and the sense of the presence of the evil 
which I had shrunk from so long weighed down upon me with crushing 
weight. After a while my spell of hypochondriacal despondency 
passed off, and I settled down into the way of living which I adhered 
to as long as I remained there. As to getting acquainted with my 
neighbors, or having any intercourse or dealings with them, that was 
altogether out of the question. ... I now had more of the feeling 
of constraint, from the knowledge that I was moving under the eyes of 
people who were strangers to me, than the strangest of the strange 
could be to a person of the ordinary stamp. Sometimes I heard re- 
marks which did not affect my feelings flatteringly, but that was not 
common. 

"Along in June I had a worse spell than common of the kind of 
nervous stagnation or will-impotence of which I have spoken, and per- 
petrated some quite irregular acts before my fetters became slackened. 
In my despair I tore the collar from my shirt, tore the slippers I was 
wearing, dashed my fist into a tempting dish which my mother was 
offering me to eat, and other things of the kind. The house we occu- 
pied was owned by a maiden lady who lived with her sister in part of 
the house. ... In the evening, after the other sister returned, 
who had been absent during the day, I overheard a few words which 
showed plainly enough that the events of the day were being discussed 
in no very gratified humor. It was evident that my acts were severely 
reprobated." 

The next day the justice of the peace called upon him and admonished 
him to restrain himself, hinting of the asylum. Of this our author 

says : 

"The dragon's tooth of reprimand that had been left in my mind 
grew into a monster, in whose presence I found it impossible to live, 
and I had a fresh access of despair. It was a hot June morning. I re- 
member seizing a razor and flourishing it, and saying, ' Show me that 
rascal and I will slaughter him,' or words to that effect, meaning, of 
course, the justice of the peace." 

Both homicidal and suicidal inclinations had long been haunting the 
secret corners of his mind, for three years before he tells of buying a 
pistol for the express purpose of making way with himself or some one 
else. On this day, after meeting the officer, he determined upon suicide. 
He walked out to two different country stores and bought ammunition. 
On his way back he passed some men in a field. They all looked at 
him, and one of them " laughed loud and mockingly, and then cried out, 
in a sort of squealing way, the intention of which could not be mis- 
taken." Then he played a game of croquet with a young man at his 
uncle's, and overheard the young man make a covert and derisive re- 
mark. He continues : 

1 ' I passed the next day in brooding, silent melancholy. It was a 
rainy day and in accord with my feelings. . . . That night I 
wrote a little statement to be left behind. ... It can not be said 
that I plunged thoughtlessly into the gulf of self-murder. I had from 
the first gaged the responsibility I was taking on myself, as fully as 



844 MENTAL DISEASES. 

my mind was capable of doing it. I felt the whole weight of the con- 
demnation that rested upon me for committing such a deed. . . . 
I passed some part of the hours of the night in sleep. In the morning 
my mother came to the door to see how I was, and I grasped her hand 
with a gesture of agonized despair. She took it as an indication that I 
was going to have one of my wild spells again, and, as she told me 
afterward, began to anticipate some work of demolition after I should 
come down-stairs. After she had gone down, I went and took the pistol 
from the stand-drawer, put on a fresh cap, got into bed again and 
propped up my head on the pillows, placed the muzzle of the pistol 
against the center of my forehead, and fired. ' ' 

He lost considerable blood from the scalp-wound, but the bullet had 
glanced off; and, although he now tried to starve himself, he was up 
and about in a few days as usual, attending to his garden with bandaged 
forehead. He continues : 

' ' There were some steps taken toward getting me into an asylum 
after my abortive attempt at suicide, but as there were difficulties about 
it, and I appeared perfectly sensible and rational, my relatives concluded 
to let it rest. 

' ' From the time of my shooting until the next spring there was not 
much that deserves mention. How were my thoughts about suicide ? 
It must be said that I had not totally renounced that idea. . . . 
I used very often to scan the beams in the wood-house and the coils of 
clothes-line in the garret. . . . The old difficulty of giving way 
under the slighting or displeasing demonstrations from others remained 
as bad as ever. I remember once I was so wrought upon by some 
trifling thing said or done by one of my relations that I kicked out the 
bottom of a cane-seat chair I was resting my feet on, in a sudden par- 
oxysm of impotent emotion." 

About this time he also made a futile attempt to poison himself by 
drinking a bottle of strong tincture of valerian that he had made 
himself. That incident he describes, and then proceeds : 

' ' It was my intention, when I began this sketch of my life, to give 
greatest prominence to that part beginning with my troubles in Clinton 
Street — that is to say, the period of confirmed lunacy with hallucinations, 
according to the world's avowed decision; but it appears at present that 
my project is not to go into fulfilment. I have been greatly delayed in 
doing as much as I have by lack of strength. 

' ' To make the account which I have given as full an exhibition of 
my condition at the time my hallucinations, if such, appeared, I will 
note some further defects in my mental action which I had noticed up 
to this time. First, two or three things indicating original lack of 
control over the brain by the will, or non-identification of my will with 
the action of my brain, and which I must count for predisposition. 
I have been troubled from my boyhood with a tendency of my brain to 
see things it ought not to see in what is placed before my eyes. This 
refractoriness does not extend to all kinds of monstrous visions, but is 
limited to the singling out of the lineaments of the human face in the 
outlines of objects seen. The annoyance I have experienced from this 



PARANOIA. §45 

has varied greatly, according to the state of my health. When I used 
to be sick with the fever and ague, I would lie in bed and gaze at the 
coarsely daubed window-shades in my bedroom, until I had made out 
every possible kind of a profile that could be distinguished. 

' ' The other of the two most serious abnormal peculiarities is the 
supplying of missing articulations to vocal sounds, heard but not 
understood distinctly, so as to give my mind the impression of certain 
words, at the same time that I knew I had not understood. Sometimes 
I have been really cheated this way, and only found it out by inquiring 
afterward. This might not give conclusive proof of the deception, it is 
true. Not to violate privacies, I will illustrate supposititiously. If 
it were proclaimed aloud, far enough from me to allow the inflections 
but not the articulations to reach my ear with certainty — 

We See Where Lies the Dreadful Secret ! 

my mind might involuntarily and instantaneously reshape it in such a 
way that I would understand : 

Deceive Where Lies Were Ever Sacred ! 

1 ' My attention was always quite easily disturbed by noises, par- 
ticularly talking. In boyhood the sound of voices in conversation at a 
little distance after I had retired to rest often gave me very serious 
annoyance, showing excessive irritability of the brain. 

' ' Such was my mental state on the eve of my being overtaken by a 
more marvelously awful fate than ever fell to the lot of mortal man. 

"My original purpose was to follow the incidents having a bearing 
on my mental fortunes with tolerable minuteness, in an unbroken chain, 
up to the time of reaching that wonderful state in which I have existed 
for the last six and one-half years. 

' ' I shall be obliged to confine myself more to generalities. 

' ' I was in such a towering state of morbid sensitiveness that a slight 
tinge of impertinence, brusqueness, or fancied contemptuousness in the 
manner of those I met, put me on the rack at once. ... It began 
to occur to me after a little that my ears were becoming wonderfully 
acute for such things. Very often I would hear lively discussions on 
my character, and disputes about the proper epithets and titles to be 
applied to me, which I understood perfectly at an astonishing distance 
off. ... I was wrought up to such a pitch that I formed a resolve 
that if I were given a sufficiently open provocation, I would attempt a 
bloody revenge, and on one occasion went out with a razor in my 
pocket. ... I had an oppressive feeling of impotence, as if para- 
lyzed, and suddenly did things I had no intention of doing, as in 
breaking glass. ... I had a soreness all through my limbs which 
I compared to molten fire running through my nerves. 

' ' I began to hear responses to and comments on my performances, 
and it gradually dawned upon me that I had been making myself a 
conspicuous object of curiosity to the whole neighborhood. . . . The 
comments heard grew more numerous and more and more derisive. . . . 
I had no suspicion at the time of any of the inspiration being drawn 
directly from my head. I do not say it was so. This is the debatable 
ground. ... It was not until about a week later that it became evident 



846 MENTAL DISEASES. 

to me that I was hearing my own thoughts given expression to by 
foreign wills and voices. 

' ' I heard a great deal about ' inducting, ' ' conducting, ' ' sphere of 
influence, ' sometimes even ' poles, ' positive and negative, and my brain 
was constantly compared to a magnet. ... I could find no better 
explanation myself for a long time than the theory of a fluid, similar to 
or the same as electricity, uniting brains. 

' ' One was the story of an English physician who had become ac- 
quainted with my magnetic properties, and who was on the spot at the 
beginning, directing the experiment. He was stated to have been the 
first to form a perfect communication with the inducted brain, and he 
had drawn off my entire memory back to childhood, and had delivered 
it verbally in the presence of reporters from the city, who had taken it 
down. It was stated that the record was preserved in a number of thick 
volumes. These he had taken with him when he sailed for England 
during the most prosperous part of the experiment. It was further 
asserted that he continued in communication with my thoughts, and 
that wherever he went every one to whom he told the story of the new 
marvel was also set in connection with the magnetic current flowing 
from my head, and began to participate in my thoughts. . . . One 
word more of the English doctor. He is said to have declared that if 
he had assisted at my birth he would not have suffered me to remain 
alive, as the monstrous character of my organization could have been 
seen at a glance. . . . After the whole earth had become pervaded 
with the magnetism from my head, it would be felt as long as I lived, 
and the instant of my death would be thus signaled all over the globe, 
and would be noted and used by all nations as a new era from which to 
reckon time. 

"I would think of the Bible, go and open it at haphazard, and just 
where my eye fell there was a passage that showed me myself. Once 
when I had been fretting about my ill success in getting my mother to 
accord with my views about my neighbors' doings, I hit upon this : 

" 'And it shall come to pass that when any shall yet prophesy, then 
his father and his mother that begat him shall say unto him, Thou 
shalt not live, for thou speakest lies in the name of the Lord ; and his 
father and his mother that begat him shall thrust him through when 
he prophesieth' , etc. — Zechariah, xiii. 

' ' But the most perfect identity of all is to be found scattered 
through the Psalms ' ' [of which he quotes several pages, and then con- 
tinues] : " I do not intend to appropriate the spirit of these passages, 
or to make their language my own, but quote them thus collectively as 
an evidence of fact. I am myself but an inquirer. Do they express 
the experience of any certain person or persons? Or are they pro- 
phetic ? . . . Can it be that the same thing that has happened to 
me has befallen another in ages long past, and that these are the traces 
of it? 

' ' I have also found a most remarkably close application of many 
of the precepts and reflections of Thomas a Kempis in his ' Imitation 
of Christ.' He seems to keep the same character exhibited in the 
Psalms in view, only speaking as a monitor, instead of in his person. 
I presume I find myself mirrored in both these places, because I am 
an extreme case. ' ' 

Gradually his delusions, burgeoning one from another, became so 



PARANOIA. 847 

systematized that in the last year of his stay at this asylum he could 
write in his book : 

' ' The signs are too many and too evident to permit me to doubt 
that my destiny is bound up with the religion of the world. I stead- 
fastly believe that the words in Jeremiah, ' Take forth the precious 
from the vile, ' are addressed to me; and I can not be recreant to the 
holiest of duties. ... I will not waste time in useless discussion, 
but start with the assumption that it is God's will that I should give 
the world my opinions. 

"If it comes to be generally believed that my sign is a fulfilment 
of Hebrew prophecy, I would recommend a transfer [of the Sabbath] 
to the day of the commandment. The very fact of a day one step re- 
moved being fixed on by both Christians and Mohammedans looks like 
an admission that another step remained to be taken. 

' ' Was it not the confidence of Jesus in the book spoken of above 
that made him say he knew the Father, when contending with believers 
in personified derangement ? ' ' 

Quite a large part of the volume is devoted to expounding the Scrip- 
tures, in accordance with his delusion that he is a prophet come to re- 
veal a new religion. 

For instance, of Babel he says : 

" I find an application for the tower of Babel in my own insane 
history. I expect a confusion of the speech of the old sects to ensue 
likewise. ' ' 

Of Abraham he remarks : 

' ' Abraham is accounted the father of all who believe in the Eternal. 
I believe I am chosen as his sign for the abolition of all dishonoring 
beliefs, as Abraham was set up against all idolators and pagans. . . . 
I have to note, in connection with the offering of Isaac by Abraham, that 
I find the date given as 1872 before Christ, coinciding with the year 
after Christ in which my ear-troubles commenced." 

Of Esau : 

' ' We may take Esau for polytheistic religion, recognizing and deify- 
ing every force and passion that has dominion over the soul and destiny 
of man. . . . When it gave up its birthright for belief in a single 
judge, it pledged itself to go on and submit to be judged by the new 
master. I believe that the day of judgment has come." 

Of the miracle of the rods : 

1 ' The rods changed into serpents signify arguments becoming living 
convictions in the mind of Pharaoh. The evangelists' rods live as ser- 
pents in the minds of Christian believers, but I confidently expect that 
my rod will become a serpent that will swallow them all without trouble. 

' ' Israel is held responsible for the destruction of the heathen and 
their idols. I conceive that I am the Lord's instrument for the com- 



848 MENTAL DISEASES. 

pletion of this work, and that I have been shown these signs in the law 
that my hands might be strengthened. 

' ' I can not shut my eyes to the fact that I have been made the 
world' s sin-offering. ' ' 

Of the prophets : 

' ' The prophets I will take in a lump, with the assurance that no 
one can fail to see their connection with my destiny. There is a 
prophecy in Ezekiel, xxxiii, 30, which is very closely paralleled in my 
experience. . . . Jonah gives me a parable. ' ' 

His discussions of theological questions are interesting, perfectly 
coherent and logical, although often fanciful. He pays tribute to the 
beautiful moral laws and righteousness of Christ, but is disposed to 
criticize His conduct as being inconsistent in one who claimed to partake 
of the omnipotence and omniscience of the Eternal. Of resurrection he 
says : 

" If I conceive of a new body having the memory which I have of 
this body's life, — and I can find no other idea of the continuance of a 
soul's life except in the perpetuation or renewal of the memory, — Avould 
that in the new body be a true memory ? Would it not be a hallucina- 
tion ? Would not that be an insane creation ? ' ' 

In speaking of the years of his greatest mental aberration, he says : 

' ' Here I come to more debatable territory, on which I and the rest 
of the world have until this present been at variance. I will, in defer- 
ence to the other side, make use of the word believe in stating facts drawn 
from the region of my memory lying within this shadowy world. I 
will be permitted to say, therefore, that I believe that after settling 
down in the before-mentioned place, my brain was, by the gradual 
progress of events occurring naturally and according to the ordinary 
laws of human affairs, drawn into relations to the living actors around 
me, of an altogether unexampled kind — at all events, different from any- 
thing plainly recorded in the annals of past ages. I believe that the final 
result of such relations was the superinducing of a state of mental inter- 
communication through the medium of my sense of hearing. 

' ' But this is a very old story, and merely a restatement of the per- 
fectly well-known features of my alleged monomania. Let me pass on 
and give, as well as I am able, my own theory on which I explain these 
phenomena, which may have more interest. It is a question of personal 
identification. How does a man use his own brain ? He can use it 
because it recognizes the actions of his members as belonging to the per- 
sonal unit of which it forms the summit. Now the question is, can not 
a human brain under certain circumstances become so perverted as to 
recognize for itself, and without the volition of its bearer, the acts of 
other individuals as belonging to its life, as falling within its own 
memory ? And if so, would not those individuals become partakers of 
the intellectuality of that brain, know its conceptions and ideas, while 
it thus recognized their motions, and become able to share its walks and 
ways ? Such I believe to have been the result in myself, from the 
towering height of disintegration reached by my mental organism, by 



PARANOIA. 



849 



the gradual process which I have endeavored to faintly shadow forth in 
the preceding five chapters. 

' • Let us see whether it does not look probable that a mind in the 
habit of separating recognized observations from its own responsibility, 
considering them objectively, philosophizing on its own manner of 
working, driving the impotent and erratically acting part into a corner, 
as it were, would not be more exposed to such a fate as supposed than 
one acting unitedly, and right or wrong as a unit. It may not be sus- 
ceptible of argument based on points of organic action, but it looks a 
plausible thing to me that the insane quality or element in such a brain 
might be acted on from without, and give itself up to such action, inde- 
pendent of the thinking will of that mind. 

' ' But let us further suppose some little abnormality about the 
original constitution, a predisposition from a slightly dislocated arrange- 
ment of mind-apparatus and sense-apparatus. 

•' ' Such, say I once more, I believe to have been the case with myself, 
and such to be the true nature and essence of the things which have 
constituted my insanity. . . . I do not deny the fact of insanity, 
but I firmly believe that it is and has been, since the summer of 1872, 
an insanity involving the will, ideas, and acts of more than one indi- 
vidual. 

' ' Notwithstanding my full and necessary faith in the reality of 
things as I have reasoned to prove them, I am still willing to concede 
that there has been more or less of purely subjective illusion mingled 
with these dual realities. Under one aspect the whole of this train of 
mental images and impressions which has whirled through my head 
has consisted of insane delusion. The effect on the state of my system 
has no doubt been analogous to that produced by delusions, and the 
nervous condition which preceded it was such as eventuates in the rise 
of delusions. Does not the development of delusions often have a com- 
pensating effect in freeing the nervous system in a manner from its 
trammels ? Perhaps when this supervenes the brain becomes a chim- 
ney for the combustion of the matters which threatened to entirely in- 
terrupt the action of the system by clogging. The patient is then 
known as sensible on most subjects, but a confirmed monomaniac."' 

Certain peculiarities in his hallucinations possess considerable in- 
terest. They almost always referred to the intercommunication of 
brains. In July, 1878, he wrote out a list of specimen phrases 
which he had heard while sitting alone at an asylum window. Some 
of these I reproduce here : 

" One thing you know, you know when you get your will in there 
you get him into a hell of misery." — " He ain't got any will there to 
fool away." — "Although you are knowing his ideas you connect with 
her will." — " Instead of connecting with his ideas you keep giving him 
to her." — "You can't get your will there till he connects his through 
to his thought." — "AYe are all the while trying to make him think 
himself." — " I think Ave ought to be making efforts to get the idea out 
on the hall." — "After they get the whole will he is in a hell of torture 
all the while." — "We keep hollering till we get him into a hell of hor- 
rors." — " You see, when there are two wills connected with the head at 
the same time, he ain't nowhere." 

54 



850 MENTAL DISEASES. 

These were the voices of several men and women. In fact, his hal- 
lucinations were always polyphonic, and at times would be polyglot. 
They did not address him directly, but spoke to one another about him. 
He seldom had hallucinations of hearing except when the ear actually 
received the sound of distant conversation or inarticulate noises ; so that 
for their production it was usually necessary that there should be trans- 
mission of vibrations to the auditory cortical area. As instances of the 
polyglot character of the voices on occasion, I relate the following : 

Once he heard some one call out, " If he ain't a prophet there never 
was a prophet — tabulas clecli ut vincerer." In tracing this Latin to its 
source, he found it was a perversion of a phrase in a note to Wins- 
ton's " Josephus " : " Egomet tabulas detuli ut vincerer " (I myself car- 
ried the letter commanding that I be bound), attributed to Bellerophon, 
which he had once read. 

At another time in a street-car, a German sitting next to him cried 
out, " Das ist das grosste Mirakel von der ganzen Welt. Jeder 
Gedanke der ihm in den Kopf gekommen ist hat die ganze Village 
gehort." (That is the greatest miracle in the world. The whole vil- 
lage has heard every thought that has come into his head.) The gram- 
matical construction of the foreign phrases is open to criticism. The 
language used by his invisible tormentors was always a peculiar dialect, 
often abounding in slang, which he considered the most hateful kind 
of language, and which was such as he never voluntarily used in the 
composition of his own sentences. The hallucinations were usually bois- 
terously satirical, teasing, quizzical, frequently accompanied by laughter. 

Course and Prognosis. — The usual course of paranoia has just 
been outlined. Many cases, however, enter into a state of secondary 
dementia toward the last. 

The prognosis is absolutely unfavorable. I do not know of a single case 
that has recovered. These patients may live to an advanced age, especially 
under the fostering care of an asylum. Remissions are occasionally noted. 

Morbid Anatomy. — The disorder is purely functional. No patho- 
logical changes have been found in the brains of paranoiacs. In some 
instances asymmetrical arrangement of the convolutions has been noted. 
These belong in the category of stigmata of degeneration. 

Treatment. — Therapy does little or nothing for the disease once it 
has become established. Sometimes complete change of environment 
brings about a remission. Constant physical occupation, hard work 
out-of-doors, is perhaps the most useful of remedial agents, in that by 
this means the mind is diverted from the constant contemplation of 
hallucinations and delusions, and through bodily fatigue is made to 
receive a considerable amount of repose. Labor acts as a counterirri- 
tant. By it episodic outbreaks of excitement may be aborted or 
reduced in intensity. Prevention naturally would be of vast impor- 
tance, were one able to anticipate the coming catastrophe in the pro- 
dromal period. Children and youths who exhibit such symptoms as 
have been described as incident to the hypochondriacal epoch of the 
evolution of paranoia require a special system of education and train- 
ing, in which occupation of the muscles and out-of-door life should 
play the chief role. 



THE NEUROPSYCHOSES. 851 

CHAPTER XI. 

THE NEUROPSYCHOSES. 

Hysterical Insanity. Epileptic Insanity. 

Under the designation of neuropsychoses are included certain con- 
ditions of a hysterical, neurasthenic, or psychasthenic character, as well 
as mental disorders associated with epilepsy, chorea, Huntington's 
chorea, and Parkinson's disease. As the mental symptoms and char- 
acteristics of these disorders haye already been described in previous 
pages under the headings of the diseases themselves, only the most im- 
portant are selected here for special consideration. 

HYSTERICAL INSANITY. 

The hysterical character gives a certain color to other psychoses when 
present in a given case. This character, having practically always a 
hereditary basis, consists in extraordinary suggestibility, instability of 
mood and activities, great impressionability, enormous egoism, which 
leads to the desire to make sensations, occasionally a form of negativism 
(giving rise at times to refusal of food, mutism, etc.), a tendency to 
simulation and confabulation, and, finally, associated with these psychic 
symptoms we may have any of the well-known nervous symptoms 
(anesthesias, hyperesthesias, paralyses, aphonia, pains, clavus, globus, 
color-blindness, amblyopia, deafness, tremor, and convulsions). The 
name " psychogenia," or " psychogeny," has been suggested to replace 
the now meaningless hysteria. Besides coloring at times various other 
types of mental disease, there may arise on this hysterical foundation 
episodic attacks of real mental disorder, such as somnambulism, with 
amnesias, hypomanic excitement, depressive phases (generally with little 
or no inhibition), and the so-called hysterical twilight conditions 
(Dammerzustande). 

These last are usually observed before or after grand hysterical 
attacks, and consist of a hallucinatory delirium, with more or less cloud- 
ing of consciousness, or of a religious ecstasy, followed by amnesias on 
recovery. In many cases there is a continuous recurrence of such de- 
liria, with lucid intervals. There is amnesia during the lucid intervals, 
which disappears in the recurring attacks, so that the same delirious 
content may be lived over and over again. The alternation is often so 
marked as to constitute a species of double personality. 

The prognosis, naturally, in any case with the hysterical character 
is very unfavorable. The episodic physical and mental symptoms gen- 
erally disappear under some sort of suggestive treatment, but they are 
prone to reappear in some other form. 

EPILEPTIC INSANITY. 

Some ten per cent, of all epileptics become insane. Hence the 
epileptic neurosis in an individual renders him about thirty times more 
liable to insanity than if he were normal. The psychoses to which the 
epileptic is subject vary extremely in character. It is my aim to give 



852 MENTAL DISEASES. 

here a brief review of these. I shall not consider under this heading 
forms of mental disorder in which epilepsy or repeated epileptiform 
convulsions make their appearance in conjunction with the psychic dis- 
turbance as the result of a common cause (general paralysis, chronic 
alcoholism, epileptic idiocy, paralytic idiocy, etc.), but shall limit myself 
to the class of insanities induced by the epilepsy. It is, first of all, 
necessary to dwell for a moment upon some of the ordinary features of 
epilepsy, apart from the familiar phenomenon of muscular convulsion. 
The epileptic is subject to peculiar symptoms, which are looked upon 
as the equivalents of convulsive seizures. Among these are sudden 
brief losses of consciousness. The consciousness may be merely clouded 
or completely lost. There may be no perceptible concomitant symp- 
toms. On the other hand, the defect of consciousness may be accom- 
panied by some pallor of the face, a fixity of the eyes, or a partial 
local spasm or movement (strabismus, stammering of a few words, 
grimaces, lifting the arm, bowing movement of the body, turning of 
the head, etc.). The disorder of consciousness may be associated with 
an automatic -dream-state, similar to somnambulism, in which compli- 
cated impulsive movements take place (automatic continuance of acts 
begun before the seizure, purposeless running, undressing, etc.). Ver- 
tiginous attacks may be the equivalent of convulsions. The aura of an 
epileptic attack may be in the form of a hallucination. A study of 
the psychology of epileptics in general gives us a sort of composite 
picture, to which all of these patients conform more or less closely.. 
The mental attitude of the epileptic is due to a variety of circumstances. 
In the first place, he has a consciousness of the dreadful nature of his 
malady." He is in a state of expectant attention as regards the sudden 
blackness and prostration which are to strike him unawares at any 
time, in any place, like the lightning from a clear sky. He can never 
share the social pleasures of his fellows. The schools are not open to 
such as he. When he becomes old enough to work, he finds that no one 
wishes to employ him. Every avenue of education, every trade and 
calling, every road to mental progress, is barred. He is a social out- 
cast, an object of commiseration, a burden to his friends, perhaps a 
family blemish to be kept concealed. The doctor is called in, and, 
taking, as a rule, a hopeless view of the case, abandons him to the 
mercy of the bromids, which further his mental, physical, and moral 
degradation. In this way the epileptic character is evolved. It con- 
sists of a mixture of melancholy, hypochondriasis, emotional irritabil- 
ity, moroseness, distrust, misanthropy, mental apathy, and dullness, 
often combined with morbid religious tendencies and modified by patho- 
logical psychic conditions incident to the ravages of the disease itself. 
These pathological mental states vary from the peculiar psychic 
equivalents just described to the actual psychoses of divers forms 
now to be detailed. Epileptic insanity is chiefly a progressive psychic 
deterioration terminating in dementia. But the progressive degenera- 
tion is frequently marked by episodic outbreaks of psychoses under 
various forms. Among these are transitory hallucinatory and stupor- 
ous disorders and chronic epileptic psychoses (under any form, such as 
mania, melancholia, circular insanity). 



THE NEUROPSYCHOSES. 853 

Psychic Degeneration of Epileptics. — As is well known, severe 
epileptic attacks are ordinarily followed by a somnolent and stuporous 
condition lasting from an hour or two to several days. The frequent 
repetition of such attacks tends to render complete recovery from such 
mental torpor more and more difficult. As a consequence, we observe a 
gradual weakening of the intellectual processes. The flow of ideas is 
retarded and the expression of such ideas along motor lines becomes 
sluggish ; the speech especially has a characteristic slowness ; atten- 
tion is diminished and memory impaired ; the concepts and judgments 
are built up with ever-slackening activity. In this w T ay the epileptic 
may sink gradually into a deepening simple dementia. In some cases 
the concepts attended with ethical feelings vanish first, and to so 
striking an extent that acts of violence, cruelty, brutality, and crime are 
committed without a single inhibitory effort or a shadow of remorse. 
These acts often have an impulsive character. 

An excessive irritability of temper is a phase of epileptic psychic de- 
generation. The most trivial incidents may give rise to outbursts of 
anger and even of overwhelming fury. 

The natural hypochondriacal depression of many epileptics is frequently 
much exaggerated, giving rise to a sort of melancholia colored by mental 
enfeeblement, and by suspicion, distrust, misanthropy, and moroseness. 

Occasionally, in the midst of this progressive deterioration of mind, 
imperative ideas and acts manifest themselves, and delirious states 
appear with dreadful hallucinations and delusions of persecution 
(paranoia-like outbreaks). 

These are the marks which distinguish the psychic side of the 
gradually developed dementia of epileptics. The mental enfeeblement 
is accompanied, as in terminal dementias generally, by increase in 
bodily weight, hypertrophy of the subcutaneous fatty tissue, and the 
gradual effacement of the lines of expression in the features. We thus 
reach ultimately the condition of 

Epileptic Dementia. — As intimated, the rate of progress of 
epileptic dementia is in direct proportion to the number and severity of 
seizures. There are cases which go on to the terminal stage without 
some of the peculiar manifestations of progressive epileptic degeneration 
just described, and others, again, in which these features are prominent. 
The dementia may be absolute, so that not the simplest concrete memory- 
picture remains in the vacant mind ; the patient needs care in his per- 
son and dress, and often has to be guided and assisted in taking nourish- 
ment. His sensibilities become so diminished that he is indifferent to 
stimulation of any sense, and has no perception of the needs of the body 
as regards the bowels or bladder. He must be cared for like an infant. 
A persistent sexual instinct often impels him to constant masturbation. 

During progress into dementia, we note the intercurrent'hallucinatory 
states already mentioned, and the accesses of anger, with assaults and 
impulsive actions of various kinds. The motor memories suffer in the 
end to such degree that all complicated movements are forgotten. This 
is particularly noteworthy in the use of words, which are separated by 
considerable pauses. Often even the syllables are thus divided. Finally, 
the patient loses the power of speech altogether (aside from the actual 



854 MENTAL DISEASES. 

aphasic attacks, which are not infrequently observed in connection with 
severe epileptic seizures). 

The course of epileptic dementia is rarely 'rapid ; it usually extends 
over a period of years. The cause of death is usually accident, status 
epilepticus, pneumonia, intestinal catarrh, inflammation of the bladder, 
or some other intercurrent affection. Epileptic dements exhibit a 
diminished resistance to diseases in general, and never attain great age. 

Acute Transitory Epileptic Insanity. — The acute insanity of 
epileptics develops suddenly before a convulsive seizure, after the attack, 
or it may occur in the interval between the epileptic convulsions, com- 
monly in the place of a convulsion, as a so-called psychic equivalent. 
As a rule, both onset and termination are sudden. The duration of the 
insanity is ordinarily from a few hours to a few days, though the attacks 
are sometimes shorter and sometimes longer. The symptoms are pecu- 
liar and various. The chief characteristic is the clouding of conscious- 
ness. The patient's state may be one of complete unconsciousness, 
though usually consciousness is not entirely lost. It is rather a condi- 
tion of subconsciousness or of subliminal consciousness, with stupor. 
Upon this screen of clouded consciousness there is a play of multiform 
and bizarre psycopathic outlines — many-hued, terrible, or ecstatic hallu- 
cinations ; delirium, mutism, incoherence, verbigeration, anxious states, 
delusions (often of a persecutory nature), or irresistible impulsions to 
assault, destructiveness, homicide, and suicide. Sometimes the funda- 
mental tone of the outbreak is melancholic, more often maniacal, but 
the most appropriate designation of these acute epileptic psychoses is, 
perhaps, acute hallucinatory paranoia. There is no essential difference 
between them, whether the attack be preparoxysmal or postparoxysmal, 
or the equivalent of the paroxysm. 

The stupor of epileptic insanity is distinguished from that of other 
psychoses by marked loss of consciousness, enfeebled attention, anal- 
gesia, sudden violence, and confusion. 

AVe sometimes observe in connection with subconsciousness primary 
anxious states, resembling precordial dread, with extremely painful 
sensations of oppression and suffocation in the breast ; and much more 
rarely primordial exaltation, with acceleration of the stream of ideas. 

Hallucinations are mostly limited to the visual, auditory, and olfac- 
tory senses, chiefly to the first-named. The patient sees wild beasts, 
specters, flames, the fires of hell, wheels, gigantic threatening objects, 
falling walls, overwhelming waves of water ; or, on the other hand, the 
golden gates of heaven, the jasper throne, God, and the choir of angels. 
He hears menacing voices, clamor and uproar, the thunder of cannon, 
or the singing of the hosts of heaven, the voice of God, etc. Disagree- 
able and noxious or pleasant odors may be perceived. A peculiarity 
of these hallucinations is a certain monotony of character, a general 
sameness, in great part due to the rather child-like constitution of the 
mind of epileptics. Their education and mental evolution are so often, 
from the nature of their malady, hampered and retarded, that they pass 
through life with the fancy and understanding of a child. 

Incoherence of speech and lack of orientation as to surroundings 
are more marked in epileptic insanity than in any other psychosis. 



THE NEUROPSYCHOSES. 855 

The motor symptoms vary extremely. Sometimes we note motor 
inhibition attaining to complete immobility and mutism, lasting for 
hours, days, or weeks at a time. Such quiescence is often interrupted 
by sudden explosive acts of violence. Again, in other cases, we ob- 
serve agitation, restless wandering about, purposeless and impetuous 
running hither and thither, assaults, destructiveness, and, rarely, com- 
plicated acts, like theft and other petty crimes. A condition of relig- 
ious ecstasy is not uncommon. The patient may feel himself wafted to 
heaven, where he converses with God, Christ, and the disciples. 

In some rare instances epileptics are subject to dream-like states of 
subconsciousness, similar to somnambulism, in which complicated acts 
are carried out. Like the somnambulist, such patients may seem to be 
conscious, may comport themselves in speech and conduct in a perfectly 
natural manner, and in this condition, which may last for hours, days, 
or even weeks, commit offenses against the law, wander orf as tramps, 
or do some extraordinary thing in following the imperative, childish, 
silly, or fantastic ideas which control their dream-state. 

The disorders of memory incident to transitory epileptic insanity 
are both interesting and important. There may be, upon recovery, ab- 
solute amnesia as regards everything that has taken place. There may 
be remembrance of much that has occurred immediately after the in- 
sanity has passed, with subsequent amnesia. There may be complete 
amnesia at first, with glimpses of remembrance afterward. There is 
rarely any persistent recollection of the events of the psycopathic state. 

As has been stated, the rule is for these transitory epileptic insanities 
to exhibit a sudden onset and a sudden termination. The longer the 
duration, the less abrupt the cessation. The majority of these patients 
recover, but recurrence is,, of course, frequent. Termination in a chronic 
condition is rare. Occasionally, death takes place from exhaustion, in- 
tercurrent maladies, or from a convulsive seizure or series of attacks 
during the psychosis. Recurrences tend to hasten a psychic degenera- 
tion ending in dementia. 

The epileptic nature of such insanity as is here described, where the 
history is not known, is determined by the following characteristics : (1) 
Sudden onset and abrupt termination ; (2) the terrifying or ecstatic 
nature of the hallucinations and delusions ; (3) disturbance of conscious- 
ness and stuporous condition ; (4) impulsive acts ; (5) dream-states ; (6) 
amnesia. 

Chronic Epileptic Insanity. — Aside from epileptic dementia, the 
acute epileptic psychosis just described may take a chronic course, or 
assume a periodic form, with little improvement in the intervals between 
the exacerbations. There are cases which closely resemble chronic 
mania in their long course, and others in which melancholia is the pre- 
dominating feature. The epileptic attacks to which these patients are 
subject are naturally the distinguishing feature, and a special color is 
given such cases by the epileptic psychic degeneration. Occasionally a 
true circular insanity is presented, with its alternating maniacal and 
melancholic phases. 

Treatment. — Most cases of pronounced epileptic insanity require 
commitment to an asylum. Their proclivity to sudden accesses of rage 



856 MENTAL DISEASES. 

and fury and to impulsive acts of violence necessitates this course. 
Where there is simply a moderate amount of psychic degeneration this 
course is not necessary. 

The treatment should be, in the first instance, prophylactic ; but, after 
the development of the psychosis, it consists of a combination of the 
treatment of ordinary epilepsy with that of the particular type of insanity 
presented. 

Preventive therapy is concerned with the counteraction of the many 
elements which favor mental deterioration, with the mitigation of the 
epileptic's early sufferings, with the reconstruction of his environment. 
It may be called the moral and manual method. The moral part of it 
is the opportunity for education, regular occupation, and recreation. 
The manual and hygienic part of it, the acquisition of out-of-door trades 
or callings — muscular exercise, which in itself serves to reduce the 
number and intensity of convulsive seizures. I may be pardoned for 
dwelling somewhat longer on this subject of preventive therapy, and for 
allowing my pen to go over the same lines which it has traveled so 
often in past years, because I am convinced that this moral treatment 
marks the greatest stride in advance made for centuries in the thera- 
peutics of epilepsy. For ages drugs have been exploited as helpful or 
curative ; but, after all, little has been accomplished from the standpoint 
of materia medica. Only of late years has the moral treatment become 
prominent. As a rule, the epileptic patient was dismissed by his physician 
with a prescription of uncertain value and possibly a few general direc- 
tions as to diet. It was not known to the practitioner — or, at least, he 
did not concern himself about the matter — that the epileptic could gain 
admission to no hospital of any kind ; that he had no associates, occu- 
pation, or recreation ; that, debarred from the schools, he grew up un- 
educated, and with a tendency toward retrogression rather than progress ; 
and that, without teaching, reared in idleness, suffering from a dreadful 
malady, neglected in body and mind, he could find shelter at last only 
in the almshouses and insane asylums, these being the only institutions 
open to him. Yet, in by far the majority of cases of epilepsy, the 
attacks rob them for but brief intervals of the capacities for study, 
work, recreation, and social pastimes, which they possess in common 
with their more fortunate fellow-men. Hence the adoption of a scheme 
of colonization of epileptic dependents on the model of the great German 
colony at Bielefeld, of which the Craig Colony, in the State of Xew 
York, is an example. The Craig Colony consists of a tract of nearly 
nineteen hundred acres of land in the most fertile, productive, and pictur- 
esque valley of the State (the Genesee Valley). Upon this are already 
some sixty to eighty buildings, with accommodations at present for but 
840 patients. Over eleven hundred epileptics are now on the list of 
patients awaiting admission. Here they are to be given an education 
in the various branches of learning taught in the public schools, to be 
instructed in every kind of industry, to be treated each and every one 
for epilepsy, and to be offered a home in a sort of village life, where 
they will no longer have the feeling of social ostracism, or be debarred 
from the privileges of intellectual and moral development enjoyed by 
the rest of mankind. 



THE NEUROPSYCHOSES. 357 

The out-of-door life in a farming community has already had 
wonderful results, which may be learned from the annual reports of 
the colony. It will suffice to say here that the average reduction in 
frequency of attacks among all the patients has been fully fifty per 
cent., and that the mental and moral regeneration of the beneficiaries 
has been truly remarkable. What the effect of such change of environ- 
ment must be as a prophylactic against psychic degeneration and insanity 
can not be estimated. We may now briefly touch upon the medicinal 
and surgical treatment of epilepsy. The old drugs — borax, nitrate of 
silver, belladonna, and the bromids — have their uses. One is valuable 
in one case and not in the other ; and each patient, where the disease is 
idiopathic, and no etiological indication exists for the preferment of an 
especial agent, must be experimented upon with one drug after another 
for two or three months at a time, until a satisfactory remedy is discov- 
ered. Upon the Avhole, the bromids are most effective as a general 
antispasmodic for all cases. While the bromids are, perhaps, the most 
useful remedy we can employ as an antispasmodic in many cases of 
epilepsy, their exhibition in every case is not advisable. With a con- 
siderable number of patients the bromids are entirely ineffectual ; with 
no small number, too, very serious symptoms, such as acute bromism, 
increase of seizures, and even insanity, supervene upon their use. In 
many of the cases where actual good is done by the bromids in reduc- 
ing the frequency and severity of the attacks, the concomitant symptoms 
are such that it becomes questionable whether the remedy be not, after 
all, worse than the disease. The writer makes it a practice, therefore, to 
exhibit the bromids with caution, and never to employ them until the 
series of less harmful, but often quite as efficacious, remedies for epilepsy 
have been tried in vain. 

There are some new drugs and remedial methods that have come 
into vogue of late which are worthy of attention. In the first place, 
there is simulo, a South American plant of the hyssop family, the tinc- 
ture of which is given in doses of one to two or three drams three times 
daily. After an experience in many cases for several years, I would 
say of simulo that it deserves trial in most cases ; that it is perfectly 
harmless, which can not be said of the bromids, borax, belladonna, and 
some other drugs ; that in a few cases it has been extremely beneficial 
in my hands, and that in most cases it has no effect at all. Simulo 
combined with small doses of bromid acts very well. The so-called 
opium-bromid treatment of Flechsig is of value for many patients, 
especially in old and obstinate cases where all other agents have proved 
ineffectual. This treatment consists of the administration of opium for 
some six weeks, beginning with one-half to one grain three times daily, 
and increasing gradually until ten to fifteen grains a day are taken, when 
the use of opium is suddenly stopped, and bromids in large and grad- 
ually reduced doses are given (thirty grains four times daily, to begin 
with). I had used in certain cases of epilepsy for some years codein 
with considerable success, but this combination of the opiate with bro^ 
mids is still more satisfactory. 

Adonis vernalis conjoined with the bromids, as recently suggested 
by Bechterew, is an efficient method of treatment, from which, in several 



858 MENTAL DISEASES. 

instances, I have had gratifying results. Digitalis, which has proper- 
ties similar to Adonis vernalis, Avas formerly frequently given in 
epilepsy, but the new combination seems to be much more efficacious. 

There are a few cases of epilepsy in which careful investigation indi- 
cates self-intoxication as a factor. In these an excess of ethereal sul- 
phates (indican) in the urine, together with periodical or constant attacks 
of gaseous diarrhea, are almost positive manifestations of putrefactive 
or fermentative changes taking place in the alimentary tract. It is re- 
markable how much benefit may be obtained in such patients by the 
regulation of the diet (milk and its modifications, koumiss, matzoon, 
somal, rare or raw beef, eggs, green vegetables, and special breadstuffs, 
like Zweiback, Huntley & Palmer's breakfast biscuits, and Voebt's 
biscotte de legumine), by the frequent drinking of hot water and the 
occasional flushing out of the large intestine by hot water, and by the 
use of certain intestinal antiseptics, given two hours after eating, with 
plenty of water (beta-naphtol or salol, gr. v). 

The remarkable effect of the thyroid extract upon general nutrition 
would naturally suggest the advisability of its administration for experi- 
mental purposes in some of the nervous diseases which we are accus- 
tomed to look upon as due to nutritional disturbances in the nervous 
system. With this idea in view, I have employed it in a good many 
cases of epilepsy, in a number with very good effect. Especially note- 
worthy was mental improvement in several cases of epilepsy with 
apparently considerable dementia. It is worthy of more extended trial. 

Aside from the remedies for the epilepsy just described, we need 
occasionally to employ certain other drugs for particular conditions, 
such as status epilepticus, maniacal outbreaks, pronounced melan- 
cholic states of terror, etc. In status epilepticus rectal injections of 
chloral, gr. xx, with an ounce of starch-water, repeated at intervals of 
two or three hours if needed, give the most satisfaction. In great ideo- 
motor excitement we should use hyoscin, hyoscyamin, or duboisin 
hypodermatically, in doses of -y-^- to -j^ of a grain. In anxious melan- 
cholic conditions morphin hypodermatically is, perhaps, the best allevi- 
ating agent to exhibit. 

The question of trephining must naturally come up in certain cases 
of epileptic psychoses where trauma to the head is evidently the cause 
of the epilepsy and psychic degeneration. The following points are to 
be taken into consideration as a guide in this matter : 

1. In the very small number of cases having injury to the head as 
a cause the epileptic habit is so strong, and the changes in the brain 
are usually so old and deep-seated, that an operation, as a rule, does not 
cure, and seldom permanently diminishes the frequency of the attacks. 

2. Of miscellaneous traumatic cases, where a surgical procedure 
seems justifiable and is undertaken, a cure of the epilepsy may be 
reasonably expected in, perhaps, four out of every hundred cases 
operated upon. 

3. The removal of a cicatrix from the cortex, supposed to be the 
epileptogenic nidus, will naturally be followed by the formation of a 
new cicatrix in the surgical wound — the creation, therefore, of a new 
epileptogenic center. 



IDIOCY. 859 

4. The more recent the injury, the greater will be the promise of 
lasting benefit. 

5. In cases of traumatic epilepsy with marked epileptic psychoses 
(recurrent attacks of rage, fury, violence, destructiveness, etc.) trephin- 
ing would be justifiable as a possible means of diminishing the severity, 
danger, and frequency of the maniacal attacks, even though the epilepsy 
itself or the psychic degeneration might not be improved. 



CHAPTER XII. 
IDIOCY. 

Definition. — In attempting to make a good definition and prepare 
a classification of idiocy, we meet with much the same difficulties as 
exist in connection with the allied subject of insanity. The innum- 
erable definitions and classifications of insanity by different authorities 
are familiar to all students of morbid psychology. Each author feels 
called upon to be original in this particular, or at least to modify and 
improve upon the dicta of previous writers. This confusion is quite 
parallel in the matter of idiocy ; and it is easy to understand why this 
should be so, for in both conditions we have deviations from the normal 
mental state of every possible shade and degree, depending upon a most 
varied pathology. The etiology is complex, and the psychic and 
somatic symptomatology multiform. There is no wonder, then, that 
the clinical picture is hard to draw, and the arrangement into clinical 
types difficult in the extreme. It is impossible to make any comparison 
between the psychological state of idiots and that of normal children, 
for the former is not only one in which the mental faculties are 
diversely undeveloped or impaired as regards their quantity, but there 
is infinite variation in the quality of the idiot's psychic functions. 
Likewise it is impossible to contrast the mental organization of the idiot 
with the intelligence of the lower animals, for the idiot is always 
abnormal, while the animal is a normal being in the zoological series to 
which he belongs. 

What seems to be desirable in a definition is that there should be 
expressed in it the condition of mental weakness existing, the facts that 
the condition may be congenital or acquired, and may be due to a 
defect or some disease of the brain, and, further, that the condition is 
one belonging to the developmental period of life. A definition some- 
thing like the following would seem to me to fairly express these 
desirable points : 

Idiocy is mental feebleness due to disease or defect of the brain, con- 
genital or acquired during its development. 

Classification. — As regards classifications, they have been made 
upon a basis of symptomatology, psychology, etiology, craniology, 
teratology, and, to a certain extent, of pathology. But it seems to the 
writer that the time is not yet come for an accurately scientific classi- 
fication of the forms of idiocy. It is much the best plan at present to 
adopt an artificial grouping, chiefly clinical, but pathological to the 



860 



MEX TA L DJSEA SES. 




Fig. 315. — Diplegic idiot. 




Fig. 316 —Extreme hydrocephalic idiocy, with diplegia. 



IDIOCY. 



861 




Fig. 317. — Cretin aged thirteen years standing beside normal brother aged four years (showing dwarf- 
ing of growth). 




Fig. 318. — Hydrocephalic imbecile. 



Fig. 319. — Idiot with multiple sclerosis 



862 



MENTAL DISEASES. 




Fig. 320.— Microcephalic idiocy— wild, restless, quar- 
relsome, perverted. 



Fig. 321.— Hydrocephalic feeble- 
mindedness. 




Fig. 322.— Microcephalic idiocy. 



Fig. 323-— Paraplegic idiocy. 



IDIOCY. 



863 




■■■' 




Fig. 324.— Microcephalic imbecile— good-natured 
and a fair worker. 



Fig. 325.— Good-natured imbecile— fair 
worker. 




Fig. 326.— Two epileptic idiots 



864 MENTAL DISEASES. 

extent of our latest knowledge. Almost any of the types of the 
divisions here made use of may be congenital or acquired. The term 
idiocy itself is generic, including as it does all degrees of mental 
impairment in early life. But the variations in degree or intensity of 
the mental weakness are indicated by the expressions : idiocy, for the 
lowest degree of mental disability ; imbecility, for a higher degree, and 
feeble-mindedness, for the cases of idiocy in which the psychic faculties 
have their highest development. There is some confusion in literature 
as to the exact limitation and application of these degrees. Sollier has 
made an attempt to distinguish idiocy and imbecility, but his definition 
of imbecility is not tenable, in the opinion of the Avriter, for he 
describes a certain small class of imbeciles as representative of the 
whole order. It is to be remembered that in each of these degrees we 
have many gradations, and the entire series, from absolute idiocy to a 
normal state, leads up by progressive stages through various types of 
idiocy, several steps of imbecility, and numerous shades of feeble- 
mindedness, until the borderland between the highest degenerate and 
the normal individual is almost indefinable. 

The highest group includes a rather well-defined class of feeble- 
minded : the " backward children/ 7 the enfants arrieres of the French, 
the tardivi of the Italians, and the Geistig-zuruchgebliebene of the Germans. 
The difficulty is not so much in the delimitation of this class, as in the 
separation of the group of idiots and imbeciles. It is easy to make the 
classification on seeing the cases, but to convey to others the differentia- 
tion by description is far from being so, because of the many features — 
physical, motor, and mental — which are concerned in such division. 
The writer, while employing the term idiocy often to include all of 
these degrees, would define the idiot proper as an individual able to 
give little or no care to his person ; incapable of intelligent com- 
munication, barely able to express his material wants, most awk- 
ward and ungainly in his movements, if he move at all, and presenting 
marked evidence in his lack of expression, apathetic attitudes, and physi- 
cal stigmata of degeneration, of the profound stunting of his mental and 
physical development. On the other hand, the imbecile is able to care 
for his person and dress, attend to his physical wants, comprehend 
fairly what is said to him, carry out orders more or less intelligently, is 
often able to speak well (though sometimes speech may be impossible 
to a very intelligent imbecile) ; if not paralyzed, he has good use of all 
his muscles ; he is not destitute of expression, though the expression 
may vary from an evil, mischievous, cunning cast of countenance to 
one of rollicking good nature ; there are fewer stigmata of degenera- 
tion in this class than among idiots. 

The clinicopathological grouping of the varieties of idiocy which 
the writer has found most useful to him in his work at the Randall's 
Island Hospital for Idiots is as follows : 

1. Hydrocephalic idiocy. 

2. Microcephalic idiocy. 

3. Paralytic idiocy. 

4. Epileptic idiocy, 




Fig. 327.— Epileptic idiocy. 



Fig. 328 — Imbecile, with extreme dolichoeephaly. 
(Length-breadth index, 51.) 




Fig. 329. — Hemiplegic idiocy. 
(Blainville ears.) 



Fig. 330.— Microcephalic imbecile. 




Fig. 331.— Idiocy as a result of dementia from acute 
insanity in childhood. 
55 



Fig. 332.— Epileptic idiocy. 

865 



866 MENTAL DISEASES. 

5. Traumatic idiocy. 

6. Sensorial idiocy. 

7. Meningitic idiocy. 

8. Myxedematous idiocy, or cretinism. 

9. Amaurotic idiocy. 
10. Idiots savants. 

It is impossible, in the brief space allotted this subject, to discuss 
these various forms of idiocy in detail. The reader must be referred 
to special works and articles on idiocy — to the general works of Downs, 
Shuttleworth, Yoisin, Sollier, etc. — and to the monographs by the 
writer and others. Hydrocephalic, microcephalic, paralytic, epileptic, 
and traumatic idiocy are readily recognized by their symptoms or history. 
Sensorial idiocy is a form due to the congenital or early loss of two 
such senses as sight and hearing. Properly treated, these patients are 
capable of normal mental development (Helen Kellar and Laura Bridg- 
man). Meningitic idiocy can usually be diagnosticated only by autopsy, 
unless the history or exacerbations in the course of the disease demon- 
strate its origin. Cretinism is a rare form which has been fully 
described in many brochures in recent years. The amaurotic form is 
still rarer. There are only two of these in the RandalPs Island 
Asylum among many hundreds of idiots. 

The term Mongolian idiocy tends continually to reappear in the liter- 
ature of the subject, especially in English and American publications. 
I have never been able to convince myself that such a distinction has 
any justification whatever. I have seen several cases where the features 
had some resemblance to what might be called the Mongolian face, but 
all could be classed under one or the other of the above headings, and 
such physiognomies would seem to be purely fortuitous. 

The term idiots savants is applied to all such idiots, imbeciles, or 
feeble-minded as exhibit special aptitudes of one kind or another, 
always out of proportion to their intellectual development in other 
directions, and often remarkable as compared with similar accomplish- 
ments or faculties in normal individuals. 

There are many cases of the kind recorded in literature, and it is 
not at all uncommon to hear of idiots in our newspapers and museums 
who are exhibited as musical prodigies, " calculating boys," and the 
like. Beyond the fact of the existence of such curiosities, and the record 
of their deeds, there has been little or nothing written in explanation of 
these phenomena. The psychology of the condition is exceedingly 
obscure ; and even were the psychological processes which underlie special 
aptitudes understood, there would still remain the mystery of the mani- 
festation of particular talents or faculties in minds otherwise blank or 
defective. 

The aptitudes may be summarized as follows : 

Arithmetical faculty, musical faculty, special memories, imitative 
faculty, modeling faculty, delineative faculty, faculty for painting, apti- 
tude for games (draughts, etc.), aptitude for buffoonery. (See article by 
author on " Idiots Savants " in Appleton's " Popular Science Monthly," 



IDIOCY. 



867 



December, 1896, in which a history of some remarkable examples is 
given. See also page 875 of this book.) 

General Etiology. — There are nearly twice as many male as female 
idiots. In idiocy due to prolonged or difficult labor, this disproportion 




Fig. 333.— Paraplegic idiocy. 



Fig. 334.— Idiocy after acute insanity of childhood. 
Peculiar tic of fingers. 




Fig. 335.— Two imbeciles, one epileptic and one of unknown origin (both homosexual perverts). 



is even larger (three males to one female) — a fact to be explained probably 
by the larger size of the male infant. The causes of idiocy may be classi- 
fied as follows : 



868 



MENTAL DISEASES. 



Hereditary transformation of nervous and mental diseases. 
Pathological heredity in the form of vitiating diseases or habits (tu- 
Degenerative I berculosis, rheumatism, gout, herpetism, syphilis, alcoholism, etc.). 
Sociological factors (extreme youth of parents, extreme age of 
parents, disproportionate age of parents, consanguinity). 



Adventitious 



M- . i j Trauma, shock, fright, diseases, maternal 
Maternal j i mpreS sions. 



Gestational 



Parturi- 
tional 



Fetal 

Disorders 



Syphilis, heart disease, arteritis, morbid 
processes in the brain and meninges, 
twin pregnancy. 



f Difficult labor, primogeniture, premature birth, 
•j asphyxia at birth, instrumental injuries, pressure 
I on the cord. 



f Convulsions, cerebral diseases, trauma to the head, 
Postnatal -j febrile diseases, mental shock, sunstroke, over- 
( pressure at school. 



The relations of heredity to idiocy are much the same as those of 
heredity to the psychoses described in the chapter on General Etiology of 
Insanity. The statistics available (such as those of Shuttleworth and 
Beach, Langdon Down, Kerlin, and Piper) seem to show neurotic in- 
heritance in about forty to fifty per cent, of idiots. The stigmata of 
degeneration, which are so marked in idiocy, are described in an earlier 
chapter. As regards tuberculosis and scrofula in the parents, the per- 
centages of these authors vary from fifteen to thirty per cent. Alco- 
holism takes a high place among the causes of progressive hereditary 
degeneration (nine to sixteen per cent.). The writer has found that 
hereditary syphilis is a comparatively rarer cause of idiocy than many 
would suppose, and this is supported by the statistics of the authors 
named above (one to two per cent.). As regards consanguinity, the sta- 
tistics show that the proportion of idiotic offspring of cousins to the 
number of idiots is very slightly in excess of the number of consanguin- 
eous marriages to marriages in general. 

Gestational causes vary, according to the statistics, from eleven to 
thirty per cent. Parturitional factors (meningeal hemorrhage from 
prolonged labor, asphyxia at birth, premature birth, pressure on the 
cord, forceps injuries, etc.) are active in about eighteen per cent. It 
may be said that forceps injuries are far less dangerous to the child than 
tedious labor. Among adventitious causes infantile convulsions occupy 
a preeminent position (over 25 per cent.). But we must remember 
that the convulsions may act as a real cause, by inducing meningeal 
hemorrhage ; or convulsions may be merely an associated symptom of 
a meningeal hemorrhage or other pathological condition due to some 
other common factor. Cerebral diseases (meningitis, hydrocephalus, 
hemorrhage, thrombosis, embolism, tumor, and abscess) follow infantile 
convulsions in the statistical table of causes (eight to nine per cent.). 

Acute febrile diseases induce idiocy in some six per cent, of cases. 



IDIOCY. 869 

These diseases are scarlet fever, measles, whooping-cough, typhoid 
fever, small-pox, and diphtheria. How they act is not yet known. 
Sometimes it is through meningeal hemorrhage induced by the convul- 
sions so common at the onset or during the course of these maladies. 
Possibly at other times it is through an infectious encephalitis, or 
microbic embolism or thrombosis. Trauma to the head, mental shock, 
sunstroke, and " cramming " at school have a small, yet appreciable, 
share in the production of idiocy (probably two to five per cent, alto- 
gether). The author has found, in his own experience, that insanity in 
children is an occasional cause of idiocy. In the adult such mental 
enfeeblement after insanity is a secondary dementia, but in the growing 
child this secondary dementia is preferably termed idiocy. 

General Symptomatology. — Since idiocy, as well as its varying 
degrees of imbecility and feeble-mindedness, depends upon some sort 
of congenital or acquired defect or disease of the brain interfering 
with its normal evolution, it is clear that the cerebral functions may 
be all of them more or less involved, and that no particular psychic 
faculty can be selected as the one whose disorder retards or influences 
the development of the other faculties. Seguin is, therefore, hardly 
correct in stating that the condition of the mental faculties in idiots is 
normal, though diminished, and that merely the will is lacking to 
give them proper direction. Sollier has given us one of the best and 
latest studies of the psychology of idiocy. 1 Following Ribot and 
others, he maintains that the slow development of the cerebral facul- 
ties is due to want of attention ; that spontaneous attention is caused by 
affective states brought into action by sensations, and that those young 
children are the most attentive whose nervous systems are most easily 
stimulated. Hence the faculty of attention is closely related to the 
activity of the sensations. The greater the power of attention, the 
more intelligent does the individual become. In idiocy, owing to the 
diminution or loss of the power of attention, the perceptions aroused by 
sensations are more or less indefinite, and the resultant idea likewise 
ill-defined. Sensations become more numerous as the organism develops, 
and the lack of ideas and recognitions becomes more noticeable. 

Following somewhat the natural order of such examination, with the 
excellent work of Sollier 2 as a guide, we first take up the senses, those 
avenues which lead to psychological development. 

Sight. — Between seven and eight per cent, of idiots are congenitally 
blind. It is necessary to determine whether the blindness is due to 
defect of the visual apparatus or to lack of attention. Blindness does 
not preclude the possibility, of education, for some idiots with defect 
of this sense may be educated to a moderate degree. When idiots can 
look, without in reality seeing, the apparent blindness is due to a com- 
plete absence of attention. In idiots less aifected, a greater variety of 
objects will attract their attention. In the higher grades of idiocy 
(imbecility and feeble-mindedness) vision may be as good as in normal 

1 " Psychologie de l'idiot et de l'imbecile," Paris, 1891. 

2 The author, while differing from Sollier materially in some of his conclusions, is 
indebted to his work for many of the details of the psychological symptoms of idiocy. 



870 MENTAL DISEASES. 

man. But many present certain visual and ocular defects, such as 
hypermetropia, defective color-vision, strabismus, nystagmus, congenital 
cataract, inequality of the pupils, microphthalmos, and the like. In 
hemiplegic idiocy or imbecility we may find hemianopia, but the de- 
termination of the acuity of vision is difficult in this class of individuals. 
The perception of different colors is often possible in the milder degrees 
of idiocy. Good biuocular vision is uncommon in idiots. The normal 
child is sensitive to light at birth. The normal child takes pleasure in 
the sight of objects as early as the eleventh day, the eyes are normally 
coordinated by the end of the second month, and he begins to distinguish 
colors correctly at about the age of two years. 

Hearing-. — There is a somewhat analogous condition of the organs 
of hearing. It is not always easy to determine whether an idiot is deaf 
from defect in the auditory apparatus or only sensorially deaf. Idiocy 
of mild degree is not infrequently induced by deprivation of this sense. 
In the higher grades of idiocy hearing is nearly always normal. Deaf- 
mutism cannot be considered as common. The normal child hears on 
the first day, and is pleased with music in the second month. 

Taste. — This sense is frequently affected. Gluttony is a marked 
feature in idiocy. It is common for idiots to eat without mastication ; 
many present a precocious taste for alcohol. This is especially true of 
the higher grades. A difficulty in distinguishing the simple tastes (salt, 
sweet, bitter, and sour) is not infrequently met with in the milder types, 
as well as in those with great mental impairment. Inversions and per- 
versions of taste are observed. The normal child evinces a sensibility 
to the taste of salt, sweet, bitter, and sour on the first day of birth. 

Smell. — In the normal child strong-smelling substances produce 
mimetic movements on the day of birth. In idiocy the sense may be 
much impaired, perverted, or absent. 

Tactile Pain and Muscular Sensibility. — As a rule, sensibility 
to touch and pain is uniformly diminished in idiocy of all degrees, 
mostly through lack of attention. There may be complete anesthesia 
and analgesia, particularly in the lower grades. On the other hand, 
there are cases in which the sense of touch may be educated to a high 
degree of delicacy. It is almost impossible to study the muscular sense 
in idiots, but it is apt to be impaired in proportion to the other senses. 
The normal child starts at gentle touches on the first day, and manifests 
muscular sense as early as the eighth week. 

Thermic Sensibility. — What has been said of touch and pain 
applies likewise to the temperature sense. But their vasomotor 
systems are susceptible to the influences of cold and exposure, and their 
resistance to external influences and diseases is such that many of them 
die of pulmonary affections. Some become more stupid in cold weather 
and brighter in warm weather, while an elevation of bodily tempera- 
ture (fever) is accompanied by evidences of more active cerebration. 

Morbid Movements. — A small number of idiots exhibit no motility 
at all, but remain perfectly inert. But the majority are apt to be in 
constant motion. These movements tend to take on a rhythmic and 
automatic character. I do not here refer to such morbid movements as 
epilepsy, athetosis, associated movements, ataxia, and chorea, often 



IDIOCY. 871 

present in paralytic idiocy ; nor to tremor, found in sclerotic cases ; but 
to a group of automatic or impulsive movements. 

These forms of movements are among the most common and striking 
symptoms immediately noticed in going through an institution for idiots. 
A very large proportion of the inmates are observed to be in continual 
motion. As a rule, the most frequent rhythmic movement is an 
anteroposterior oscillation. The patient, in a sitting attitude, sways 
his body slowly or rapidly backward and forward. Sometimes the 
oscillation is from side to side. Occasionally the hands and fingers are 
rapidly or slowly flexed and extended, and brought up to the face in 
movements similar to those in athetosis, but differing from them in that 
they are entirely subject to the will, just as are the oscillations alluded 
to. Walking to and fro, rotating, dancing, and so on, are more elab- 
orate forms of the same kind of impulsive movement. Similar move- 
ments occur in the insane, as is well known, and particularly in 
conditions of greatly enfeebled mind, such as secondary dementia. 
They are spontaneous movements, seeming to have no relation to any 
stimulation of the brain giving rise to a motor expression. Generally 
the movements cease for a time when any sensory impression, such as 
the appearance of a stranger in the room or being spoken to, temporarily 
alters the feeble current of thought or excites the mental blankness 
which has given rise to the automatic movement. Children and young 
animals are full of spontaneous movements, undoubtedly due to impres- 
sions received at some time during their lives, or, it may be, impres- 
sions inherited ; and, while these spontaneous movements of children 
are undoubtedly similar in their nature to the automatic movements of 
dements and idiots just described, they do not often present the 
rhythmic character of the latter. It is probable that in the feeble 
mind, upon which nerve stimuli seldom make an impression, the simple 
old motor expressions are retained, repeated, and become habitual or 
automatic. Automatism of movement is thus a sign of little aptitude 
or impressionability, so far as fresh mental stimulation is concerned. 
In the idiot the impulsive rhythmic movements just described may be 
regarded as the habitual motor expression of the simplest and oldest 
stimuli ; whereas, in the secondary dement, the analogous automatic 
movements are to be looked upon as reversions to the spontaneous 
movements of infancy. The smiles and grimaces of idiots and imbeciles 
belong to the same category of infantile spontaneous motor expressions. 

There is probably a certain amount of pleasure in the movements 
in many cases, as sometimes they manifest displeasure if prevented 
from executing them. There is nearly always a difficulty out of pro- 
portion to the intellectual development for idiots to perform associated 
movements with a definite object. They may be able to talk and read, 
and even write, yet be unable to dress themselves. This is often a fault 
remediable by education, according to Seguin. 

Right-handedness and Left-handedness. — Some twelve per cent, 
of all children, idiot and normal, are left-handed ; but while eighty-eight 
per cent, of normal children are right-handed, only seventy-two per cent, 
of idiots use their right hand in preference, the remaining sixteen per 



872 MENTAL DISEASES. 

cent, being ambidextrous. This peculiarity is said to be present also 
among criminals. 

Voluntary Movements. — Many idiots do not learn to walk at all, 
either because of general debility, inability to learn, or paralysis. In 
such as do acquire the ability to walk there is great retardation in its 
acquisition. This is also true of other uses of the voluntary muscles 
for the common acts of daily life, such as carrying food to the mouth, 
and so on. They are either never learned or they are acquired late. 

Organic Sensations. — The keenness of visceral sensibility is 
more or less diminished in all idiots. The sensations of hunger and 
thirst are lessened, though only very rarely absent. The feeling of 
satiety after a hearty meal is seldom felt by them ; so that if left to 
themselves, they would eat on indefinitely. The necessity of defecation 
and micturition is not perceived at all by profound idiots. In the 
lower and middle grades of idiocy it is often difficult to diagnosticate 
visceral disease, owing to the bluntness of somatic sensations, and they 
may die without giving any appreciable symptoms. This masking of 
disease in idiocy is quite analogous to the masking of disease in various 
insanities. The feeble-minded and imbeciles not infrequently mislead 
the physician by exaggeration, concealment, or falsehood. 

Attention. — The lack of the faculty of attention is one of the 
chief characteristics of idiocy. Naturally, it varies in degree from 
complete nullity to a simple diminution of the faculty, but it is always 
lessened. The fundamental elements of the faculty are deficient. 
These fundamental elements are : The integrity of sensory impressions 
delivered to the brain ; an emotional state of pleasure, pain, or interest 
in such sensations ; motor expressions in the eyes, face, limbs, or body 
of the impressions received. There are two forms of attention, accord- 
ing to Ribot and Sollier, one of which is natural or spontaneous, and 
the other voluntary, established by education. The latter can not 
exist without the former. 

There are two qualities in attention that are of importance — viz., 
intensity and duration. 

Thus, attention is impaired in idiocy by the defective senses, which 
convey to the brain feeble impressions. The second element, the affec- 
tive state, is notably lacking in idiots. The motor factor of attention 
is deranged in idiocy in a great variety of ways (general weakness, 
paralysis, contracture, epilepsy, chorea, ataxia, automatic and impul- 
sive movements, and the like). The intensity and duration of attention 
are restricted to the last degree in this class of individuals. 

The intelligence and the possibility of education depend directly 
upon the power of the faculty of both spontaneous and voluntary at- 
tention. It is probable that the faculty is localized chiefly in the frontal 
lobes of the brain. Ferrier considers it proportionate to the develop- 
ment of these lobes, and some very convincing experiments recently 
published by Bianchi make it quite certain that the frontal lobes are the 
seat of this faculty. In idiots great lack of attention is coincident with 
diminutive size of the frontal lobes. 

In the low grades of idiocy spontaneous attention is almost null, 



idiocy. 873 

and education is impossible. The higher the degree of idiocy, the 
greater the degree of spontaneous attention presented, which may be so 
appealed to as to develop it into voluntary attention, with intellectual 
progress as a consequence. With idiots, as with the lower animals, at- 
tention is always connected with the sense most perfectly developed, 
which, in the former, is that of sight. The attention of idiots is most 
easily aroused through the eyes. Exercises of the attention may thus 
be employed in the diagnosis of states of intellectual weakness. We 
find idiots without attention absolutely ineducable, leading a vegetative 
existence ; others, again, exhibiting both spontaneous and voluntary 
attention, but in flashes, as it were, of brief duration and faint in na- 
ture ; and still others more or less capable of prolonged and habitual 
attention. It is only in the last-named group of individuals that edu- 
cation is to any considerable degree feasible. The education appeals 
in some to the simplest sentiments only (such as curiosity, selfish- 
ness, the desire of reward), in others attention is aroused by appeals to 
a higher affective order (such as interest, ambition, and emulation), and 
in still others attention may be aroused and sustained by habit. 

Since the power of attention directed to external events is so feebly 
developed in idiots, it is not surprising that attention to internal happen- 
ings, or reflection, should be totally absent in all grades of idiocy. 

Kibot regards voluntary attention as habitual and disciplined spon- 
taneous attention, as an adaptation to the conditions of a higher social 
life, as a sociological phenomenon. When the development of voluntary 
attention is rudimentary, and the resulting intellectual defect is marked, 
as in the lower grades of idiocy, there are no serious consequences from 
the sociological point of view. Sollier calls the idiot e.rfm-social, and 
makes the imbecile quite distinct as ftw^-social, claiming that in the 
latter there is an undefined amount of voluntary attention, combined 
with a relative, though perverted, intelligence, which two factors render 
him often a dangerous member of society. He speaks of the instability 
of the attention of the imbecile. At one moment it may be faint, at 
another intense as in normal man. He passes from one subject to an- 
other with the greatest ease, a characteristic which may even be observed 
in his infancy. Serious matters must be continually repeated to him to 
make him understand. He grasps the first part of a sentence, and 
forms his ideas from that, without waiting for the sentence to be com- 
pleted. He frequently interrupts, and there is no time to answer one 
question before another is put. Sollier further goes on to say that this 
instability of the attention for external objects or ideas is seen also in 
the acts of the imbecile, who is incapable of intelligent labor, and accom- 
plishes his tasks, when uniform, by a certain kind of automatism, with- 
out due appreciation of the object of his work. When the object is 
understood, the imbecile believes he can attain it immediately, and, 
seeing the first step only, is prevented by failure of attention from properly 
completing the w T ork or doing it at all. He seems to forget that he has 
begun, and as a consequence, unless watched, may spoil whatever he at- 
tempts. Other imbeciles refuse to work, but make themselves very busy 
and important in watching and supervising the occupations of others. 



874 MENTAL DISEASES. 

Sollier calls them vagabonds. They wander away not knowing where, 
marching straight before them, with indifference to the welfare of the 
friends or relatives they desert ; traveling by night and hiding by day ; 
undisciplined, indolent, and mischievous. 

This attempt to separate idiots and imbeciles into two distinct classes 
of extrasocial and antisocial is, to my mind, not justifiable. Sollier 
has here described a certain class of imbeciles only, and the description 
is very true to nature, but it is only a group which does not merit an 
especial classification. As regards attention, we should still hold to the 
terms idiocy, imbecility, and feeble-mindedness, as representing degrees 
of lack of attention, from complete or almost complete absence to mere 
diminution of the faculty. The adult imbecile, in the middle grade, 
would have the varying and imperfect attention of a backward child, 
and his ideas, speech, and conduct would vary with his temperament, 
with his docility or perversity ; in short, with the innate differences of 
character and individuality, which may be as manifest in imbeciles as 
in normal children. Imbeciles may and do become vagabonds, un- 
certain, mischievous, indolent, antisocial ; but they may, on the other 
hand, be good-natured, trusty, docile, industrious. Many of them, too, 
may show special aptitudes in certain directions. As to education, the 
difficulties are that in some it is hard to attract the attention, and in 
others to maintain it. 

Reflection. — The internal form of attention (reflection of Ribot), 
in which images and ideas constitute the subject-matter, is quite defi- 
cient in the lower grades of idiocy, but is present in imbecility and 
feeble-mindedness in varying degrees. It is never perfectly developed, 
as in normal man. 

Preoccupation. — This is absent in profound idiocy and feeble in 
the higher grades. A small proportion of imbeciles are capable of 
preoccupation, but of an indefinite nature, and sometimes taking on the 
character of a fixed idea. Often their interest is not aroused so much 
by what benefits and interests mankind in general as by bad actions, 
criminal or egoistic sentiments that attract their attention and arouse 
reflection and preoccupation which may result in felony or crime. 
Many are too selfish to care for the troubles of others, and too stupid 
to have preoccupations purely intellectual. 

Instincts. — The instincts in idiocy are generally defective. The 
defect may be imperfection of development or an actual derangement 
or perversion. The instinct of hunger is present in almost all grades 
of idiocy, and is so little inhibited that it is often pushed to the extent 
of gluttony. The instinct of self-preservation is impaired in nearly 
all, absent in profound idiocy, ungoverned by proper judgment in the 
milder forms. In some there is no sense of fear, and self-injury is 
possible. In others there is a comprehension of danger and an avoid- 
ance of it, or possibly an overweening egoism which may lead to a 
belief in their power to overcome it. Suicide occurs in imbeciles and 
feeble-minded, sometimes without determinable cause, sometimes as a 
result of morbid impulse. 

Sleep is good among all classes of idiots, while in the lower grades 



idiocy. 875 

it may be both profound and excessive. Whether they dream or not 
depends solely upon the degree of mental development. 

The desire and need of voluntary muscular movement varies with 
the scale of intelligence, being absent in the profound er degrees of 
idiocy, and approximating the normal the higher the psychic develop- 
ment. The automatic and impulsive movements in some may represent 
a fulfilment of the normal need, and the extreme restlessness of others 
is surely a perversion of the natural desire. 

The sexual instinct may be absent, impaired, exaggerated, or per- 
verted. It is seldom normal. Idiots of all degrees present many de- 
generative stigmata as regards the genital organs, more numerous in 
direct proportion to the mental impairment. Among these anomalies 
are : cryptorchismus, unilateral or bilateral microrchidia, spurious her- 
maphroditism, insufficient development of the entire genital apparatus, 
hypospadias or epispadias ; defect, torsion, or great volume of the 
prepuce ; median fissure of the scrotum, imperforate meatus, abnor- 
mally large or small labia, excessive development of the clitoris, 
hypertrophied labia minora, pigmentation of the labia minora, imper- 
forate vulva, atresia of or double vagina, and uterus bicornis. 
Puberty is often retarded, but occasionally is early ; often it is normal. 
Masturbation is exceedingly common among all classes of idiots of both 
sexes. In the profound degrees it is automatic ; in the higher it is 
purposive. Onanism a deux and sodomy are frequently discovered 
among imbeciles and feeble-m hided, and sexual psychopathies of the 
most shocking nature are not uncommonly manifested in some because 
of the combination of the strong sexual instinct and absence of moral 
sensibility. 

The instinct of imitation, which is a low form of instinct, and strong 
in children and many lower animals, is one to which idiots are very 
susceptible. It is usually a purely instinctive or passive imitation, 
seldom an intellectual or active imitation. Its intensity depends much, 
however, upon the scale of intelligence to which the idiot rises. It is 
very apt to be shown in the form which is concerned with moral conta- 
gion ; so that the acts and language of the vicious, mischievous, coarse, 
and vulgar are most willingly imitated. Simulation is very common 
among the more intelligent classes of idiots. 

Special Aptitudes. — In the so-called idiots savants we note the de- 
velopment of special aptitudes, occasionally remarkable, more often 
only noteworthy in contrast to the general mental vacuity. These apti- 
tudes are usually in the direction of music, mathematics, the mechanical 
arts, building, wood-carving, drawing, painting, memory for facts or 
dates, playing games, and of a low order of wit or drollery. The occa- 
sional preeminence of some particular faculty, where all other traits are 
defective, would almost lead one to believe in a heterotopia of gray 
matter in some special locality. Music, the most sensual of the arts, 
seems to appeal especially to this class of individuals. Often the 
rhythm of it seems to influence the rhythm of their automatic move- 
ments, or it soothes their restlessness or stops their cries. Sometimes 
unteachable idiots are able to retain, recall, and hum a moderately diffi- 



876 MENTAL DISEASES. 

cult tune, while higher grades may learn to play instruments by ear, 
though not by note. Next to aptitude for music, that for mental arith- 
metic is often surprising. There are also occasional instances of the 
other talents just mentioned, and doubtless the court fools of the past, 
with their mischievous pranks and quaint remarks, were recruited to a 
great extent from the imbecile class. 

Play. — There is a lack in all classes of idiots, and in direct propor- 
tion to the degree of mental defect, of that " superfluous activity which 
is expended in the form of play." The activity and attention of normal 
children are mainly developed through play. This avenue of education 
is, unfortunately to a considerable degree, closed in idiocy. The lower 
grades, if they manifest a tendency to play at all, do so in a rudimentary 
and solitary way, and in adolescence still cling to the simple games of 
infancy. With others, higher in the scale of intelligence, there is still 
defect of the play instinct, and a proclivity often to prefer games in 
which noisiness, destructiveness, and other evidence of rather brutal 
traits are paramount. Sometimes these games are carried on good- 
naturedly ; at others, selfishness, irritability, quarrelsomeness, and a 
more or less ungovernable nature are evinced. 

Civility and politeness may be taught to many, but naturally with 
difficulty to the lower grades and to such individuals of the higher as 
are hard to train in other directions, because of innate vices of tempera- 
ment and character. 

Destructiveness, a propensity even in normal children at an early 
age, is an especial attribute of all classes of idiots. In those of low 
degree it is automatic and possibly a rudimentary form of superfluous 
activity (play), but in some individuals of the superior grades there 
seems, at times, to be a vicious satisfaction in inflicting damage or 
injury, which may even lead to the manifestation of homicidal proclivi- 
ties or a tendency to arson (pyromania). Self-mutilation or injury may 
be a result of the love of destruction in the profounder degrees of idiocy. 

Sentiments. — In the lowest forms of idiocy the sentiments and 
sensations are rudimentary, or may be altogether absent. As a rule, one 
may discover various degrees of pleasure or pain, affection, pity, fear, 
social proclivities, love of property, regard for rights and duty, obedi- 
ence, shame, esthetic feelings, curiosity, and the like. 

Pleasure and pain are indefinite or absent sensations in idiots, felt 
to a greater extent by imbeciles, and well marked in the feeble-minded. 
Joy, sadness, and anger are usually aroused by physical sensations. 
The self- mutilation of some idiots points to an absence of the pain 
sense, and idiot women have been known to bear children without ex- 
periencing the pains of labor. Idiots often cry out suddenly, burst out 
laughing, or throw themselves about, which is probably explicable by 
variations of perception in the somesthetic sense. Moral pain or 
remorse, usually wanting, is sometimes developed to a slight extent. It 
is not often that these defectives weep, and if they cry, it is but for some 
momentary pain or deprivation. They live in the present only, and do 
not concern themselves about the past or future. In the higher grades 
it is physical, seldom moral, pain that is taken note of. Pleasure is 



idiocy. 877 

as little experienced as pain in the lower degrees, and laughter is as 
infrequent as crying. Pleasure is expressed by imbeciles and the 
feeble-minded by laughter, clapping the hands, or cries, though 
laughter, even with these, is uncommon. There are, however, certain 
imbeciles that always have a good-natured smile, and laugh readily and 
excessively over nothing. Frequently the laughter is a true automatic 
movement, as infantile spontaneous motor expression. 

Affection is a sentiment not uncommon in idiocy, though it varies 
with the degree, being often rudimentary, vague, indefinite, and proba- 
bly inspired rather by the ministration to his wants than bv the care- 
taker. It is found that nearly all forms, except the lowest, appreciate 
kindness and patience, and are repulsed and made unmanageable by 
brusqueness or cruelty. With certain imbeciles and feeble-minded, 
where the moral sense is not too much obtunded, true affection for indi- 
viduals is manifested ; but when the moral sense is deficient, affection 
is elementary or absolutely wanting, so that kindness is either unappre- 
ciated or at once forgotten. 

There are variations of the same nature in love for the family and in 
friendship. Absent in the simplest idiots, it may be shown in greater 
or less degree in the higher grades. In some it is unstable, changeable, 
and influenced much by the selfishness of the individual. In others, 
again, there is a perversion of family love, so that they are hateful and 
disagreeable to their parents or brethren. It is much the same with 
friendship. Often mild types of idiocy form in asylums friendships for 
one another, though they are too often apt to be associations of a sexual 
nature or for the purpose of combining together for mischievous pur- 
poses. A true solidarity of interests or social proclivity is seldom 
observed. Maltreatment of animals by idiots is usually due to 
ignorance, but there are moral imbeciles who perpetrate cruelties on 
animals as well as human beings from pure perversity and love of in- 
flicting pain. The passion of love, when it exists, which is extremelv 
rare, is founded altogether upon a physiological basis. Jealousy is 
sometimes, though infrequently, observed. 

Pity is quite unknown in all degrees of idiocy. Some are amused or 
curious and some alarmed at the sufferings of others. 

Fear is a common sentiment in all types of cases, more common than 
in normal persons, because of the want of understanding. Often the 
simplest occurrences inspire fear. On the other hand, when much 
excited, there are types that exhibit no fear at all. 

Courage is wanting in all classes of idiocy. Anger is apt to manifest 
itself in all degrees and in every age. It is apt to be both causeless 
and paroxysmal, and to lead to the infliction of injuries upon the indi- 
vidual himself, upon inanimate things, or upon persons in the vicinity. 
The ungovernable rage is usually increased by efforts to restrain the 
patient. 

Acquisitiveness is shown in imbeciles and the feeble-minded bv a 
propensity for the collection of all sorts of useless objects and trifles, 
much the same as in cases of chronic mania. There is often a marked 
tendency to steal, sometimes deliberately, and at other times without 



878 MENTAL DISEASES. 

motive, merely to gratify the desire of possession. The lower orders 
appropriate everything coming in their way, having no regard for the 
property of others. Many can be taught acquisition as a reward for 
labor, and, on the other hand, there are some who can be made to work 
only through fear, having, as they do, an innate antipathy to occupation 
of any kind. 

With respect to rights and duty, the perceptions of the idiot vary with 
the degree of mental and moral defect. In some even inferior idiots 
these perceptions may be present, while with some the rights of others 
are never respected, though to their own they may cling tenaciously, 
and the feeling of duty may never be instilled into them, because of 
more or less moral perversion. 

Obedience and respect for authority vary, too, with the amount of intel- 
ligence and the degree of moral impairment. Quite simple idiots may 
quickly respond to the word of command. On the other hand, some of 
the most intelligent may perversely resist all attempts at discipline. 
Compensation and punishment affect them variously. Reward in object- 
ive shape or in the form of praise is seldom appreciated by inferior 
grades, and often unduly by the higher. Punishment, objective or in 
the form of blame, is useless for the simpler degrees of idiocy, where 
acts are unintentional, and in some of the more intelligent excites antip- 
athy, an unreasonable sense of injustice, and often causes them to harbor 
a vengeful feeling. 

A true religious sentiment is quite unknown in any form of idiocy. 
This is true also of the feeling of shame. The only esthetic sentiment 
found in these defectives is the love of music or rhythm, which is quite 
general among all classes, though not perhaps so noteworthy as it has 
sometimes been stated to be. Occasionally we meet with cases having 
unusual musical aptitude. It is rather a rhythmic noise which appeals 
to most of them, such as beating of a drum, hammering, the grinding of 
an organ (even if out of tune and discordant). They have no sense of 
beauty, but things bizarre, grotesque, glittering, and colossal attract 
their attention. Cariosity and astonishment are aroused more readily 
through the sense of sight than that of hearing, and are often more easily 
roused in some of the lower grades than in the higher types of idiocy. 

All classes evince a marked credulity, and often it is difficult or 
impossible to eradicate an idea once established. Fairy stories are 
especially pleasing to many of them, just as they are to children. 

Veracity is a virtue which is uncommon among idiots. Many imbe- 
ciles are particularly apt to be untruthful and deceitful with regard to 
their faults, doings, physical condition, things found in their possession, 
and the like. Naturally, the simple idiot, owing to his feebleness of 
invention, if given to lying, limits his untruths to the simplest matters, 
such as denials of accusations brought against him, etc. 

Physiognomy and Expression and Character. — Idiots all show 
deficiency in their general appearance. There is always something 
ungracious, uncouth, ugly in their figures, faces, attitudes, or move- 
ments. Very common among them are misshapen or asymmetrical 
heads, dwarfishness, lack of proportion of the limbs, stooping and 



idiocy. 879 

slovenly postures, deformities of the hands or feet, and awkward and 
wobbling gait. The expression of the face varies from complete apathy 
and absence of intelligence to a considerable play of features of a low 
order, such as constant laughing, making faces, leering, or scowling. 
Besides the absence of those facial traits which are made on the face by 
the mind, the ugliness is generally added to by asymmetry, disproportion 
or deformity of the features. The eyes may be too close together or 
too far apart, or deformed by disease of the iris, cornea, or lids, or 
by squint. The nose deviates or is malformed, the ears are unshapely 
and unequal, the mouth half open, the teeth diseased and neglected ; the 
chin deviated, prominent, or retreating ; the forehead low and bulging or 
inclined. Microcephalus, hydrocephalus, and cretinism give their own 
ugly individuality too well known to need description here. Where a 
head is shapely and a face has any vestige of pleasing lines, it is gener- 
ally fair to infer that the mental state is due to deprivation of one or 
more senses, or to the insanity of childhood. 

As to character , this, too, varies with the amount of mental defect, 
and is difficult to analyze. In profound idiots there are often sudden 
accesses of excitement without apparent cause. In higher types the 
basis of character is inconstancy, weakness of will, and blunting of 
the sensibilities, their humor depending largely upon their environment, 
showing an appreciation of kindness and resentment of ill-usage. 
Some are clever and good-natured and funny, often making sharp re- 
marks or doing amusing things, and at one time such cases were in 
great demand as court or family fools. History shows there were two 
kinds of fools made use of by royal and noble families — the true or 
natural fools (idiots or imbeciles), who were the first to create the pro- 
fession, and their crafty imitators, the artificial fools, avIio made of it a 
profitable calling. 

I should differ entirely from Sollier in his somewhat extraordinary 
distinction of imbeciles from idiots. He really selects one type of 
imbecile, while we know that there are many, and erects this single 
type into a great class which he everywhere distinguishes in his book 
as the imbecile. To him the imbecile is egotistical, boastful, vicious, 
careless, dangerous, a glutton, a vagabond, a mischief-maker, a sexual 
pervert, unstable, lazy, abusive, obscene, forgetful of kindness, venge- 
ful, shameless, and altogether antisocial. 

Language. — The primitive physical basis of language in the nor- 
mal human infant is the auditory tract and the word-hearing center. 
It is essentially receptive. Then develops the word-comprehending 
center. After this the motor speech center is developed and associated 
with the primitive physical basis, thus establishing the emissive faculty. 
This rudimentary linguistic apparatus is variously defective in idiots. 
A defect in the emissive power is not so serious, as regards intelligence, 
as one in the receptive ; for idiots of considerable intelligence may not 
be able to talk at all, while others very inferior may speak with readi- 
ness. Any part of this original physical basis of language may be 
affected, and the result to the defective individual will depend much 
upon what function is lost. The auditory apparatus may be imperfect. 



880 MENTAL DISEASES. 

The word-hearing center may not act. The word-comprehending cen- 
ter may be undeveloped. In such instances the intellect will suffer 
severely. Unlike the normal child, which comprehends many things 
said to it as early as nine months of age, in cases of this kind compre- 
hension will develop very late, or perhaps never ; yet occasionally with 
the development of the emissive power (without the word-comprehend- 
ing center) words may be heard, learned, and repeated, constituting an 
echolalia — speech without idea. Supposing the emissive apparatus alone 
to suffer, we have hearing and comprehension and the development of 
the mind, yet without the power of speech. 

Like an animal, the idiot may be intelligent, but speechless. The 
development of language and intelligence is not parallel. Sollier dis- 
tinguishes two kinds of mutism in idiots — a motor and a sensory aphasia. 
In the first he can not talk, though he understands ; in the second, 
nothing which is said is understood. Language is very late in develop- 
ment in idiots. The crowing of the normal infant is not often observed, 
but meaningless and monotonous cries take its place. The laryngeal 
sounds are earliest and best enunciated, the lingual and labial latest and 
least distinctly. Wildermuth classifies the dysarthrias and lalopathies 
of idiots into two groups : 

1. Where the disturbance of speech is the direct expression of the 
intellectual density. They lack ideas, and consequently have not the 
words for the expression of them. In the lowest degree, the idiot is a 
vegetative automaton ; in a less profound degree, he is like a child of 
two or three years, with imperfections of grammar and syntax. 

2. When the disturbance of speech is a complication of idiocy, and 
is mechanical rather than intellectual, Wildermuth has rarely found 
stumbling speech in the idiot, and never stammering. These defects 
are sometimes found in imbeciles, who, moreover, talk a great deal and 
without definite object ; who have onomatomania, and who are subject 
to transitory attacks of excessive and maniacal loquacity. 

Considerable loquacity is occasionally observed in cases of acquired 
idiocy. 

Next to hearing, the visual tract and the word-seeing and compre- 
hending centers form a great receptive avenue for language and ideas. 
Heading will be impossible to such idiots as have defect of the visual 
apparatus or these centers, and the degree of acquisition of this power 
will depend upon the degree of defect. There are idiots who learn 
merely the letters, others who acquire monosyllables, and still others 
who can be taught to read laboriously. Sometimes such reading is 
purely automatic, without actual comprehension. The higher the grade 
of idiocy, imbecility, or feeble-mi ndedness, the greater the develop- 
ment of this faculty, though few of either class ever attain to perfectly 
correct reading. 

The writing center and its association tracts are the latest portions of 
the linguistic cerebral basis to be established in normal cases, and in 
the idiot are apt to be the least well-constituted. In addition to its in- 
tellectual side, there is a complicated muscular coordination required in 
writing which also renders it more difficult for defectives of this kind. 



IDIOCY. 881 

They may be taught to reproduce letters, but the characters are mean- 
ingless to them. A few write quite legibly, though seldom or never 
well. As Sollier says, their writing is in reality drawing, and they 
like to copy printed letters, curved lines, and so on. There is a certain 
tendency to write with the left hand and to write from right to left. 

In drawing, such as learn at all copy slowly and uncertainly, with- 
out perspective, and never draw without a copy or model ; or they do 
the work impatiently, and, if given free rein, indulge in curious and 
fantastic scrawls, such as are figured in the works of Sollier, Bourne- 
ville, and others. 

Intelligence. — Since intelligence depends upon the acquisition, con- 
servation, association, and production of ideas, and these upon the con- 
dition of the sensory organs and centers and language centers, it is 
mainly in intelligence that the idiot deviates from normal man. The 
deviation varies much in degree, from almost total absence to a condi- 
tion nearly approaching the normal. The idiot has fewer ideas than 
the imbecile, and the imbecile fewer than the feeble-minded. All 
classes acquire ideas primarily in the same way as the normal infant — 
through the senses ; but while the normal child later on acquires ideas 
chiefly by means of language and imitation, the defective continues to 
make use mainly of the senses for this purpose, owing to the faulty 
development of the language centers. Preyer shows that questions 
and names are understood before the normal child can speak (nine 
months), while idiots, many years of age, may have an intelligent idea 
of the use of things, yet not know their names when heard, and be 
unable to speak them. 

As regards concrete ideas, such as the different qualities of matter, 
it is noticeable that the idiot appreciates colors (particularly red), rec- 
ognizes surfaces, avoids obstacles, and notices the difference between 
round and square, while distances and space are not comprehended. As 
Sollier correctly says, imitation, which is a source of ideas for infants, 
does not develop the intelligence of the idiot ; for to him it does not 
furnish an idea, but creates a mechanism. In the superior grades of 
idiocy imitation creates an idea which is assimilated by the intelligence ; 
but as the intelligence can not retain it, the result is the same as though 
it had not been assimilated. Still, it is not just to infer, from lack of 
intellectual expression, that there is complete intellectual inactivity. 
That ideas may exist in a brain apparently inactive is shown by the 
phenomenon of intellectual manifestation induced in idiots by severe 
pain, disease, etc. In other words, the intellectual receptivity of idiots 
may be greater than supposed, until some irritation occurs strong 
enough to show that the preceding stimuli have left their effects on the 
brain centers. Thus, Griesinger reports the case of an idiot who could 
only speak a few words until he contracted hydrophobia, when he began 
to talk of events which had taken place several years before. 

As regards the conservation of ideas, we must remember, says Sollier, 
that memory is hereditary, organic, or acquired. Hereditary memory 
is extremely complex and difficult of explanation, but it apparently 
occurs in idiots. Organic memory, or unconscious memory, — viz., of 

56 



gg2 MENTAL DISEASES. 

associated movements, such as walking, — although sometimes completely 
absent in idiots, owing to defective nerve centers and lack of attention, 
is, nevertheless, better developed than either of the two other varieties. 
For acquired memory, attention is still more a sine qua non, and conse- 
quently this is the least developed form of memory in idiots. Memory 
in an idiot develops slowly ; at first its existence is shown only by the 
stimulus of some violent excitement. This indicates that memory exists 
in so far as the conservation of the image is concerned, but not enough for 
its reproduction under ordinary circumstances. In a higher degree of 
the development of memory, the idiot can recall the memory picture by 
seeing again the original object (memory for food, memory for places). 
Local memory, which does not act by satisfaction of a natural need, is 
only found in educable idiots (remembers his own bed, etc.). This 
memory is fixed by repetition of the sensation, and has not an emotional 
basis. These varieties of memory are simple, and do not necessitate 
language. As soon as language exists, a much wider field opens for the 
memory. 

In simple idiots there is no association of ideas. The primitive 
forms of association, such as fear and the hope of reward, awaken no 
associated ideas in them, and even in the superior types of idiocy there 
is no great development of this form of memory. 

It is a curious and inexplicable phenomenon that in certain cases of 
idiocy there may exist particular, specialized memories, such as for 
musical airs, dates, and numbers, although memory, in its usual and 
general sense, may be deficient. Indeed, as a rule, the memory is feeble 
in all classes of idiocy, and even in cases where the memory is fairly 
well constituted it is ordinarily mechanical, useless to the possessor, 
automatic. 

Naturally, as abstract ideas result from reason, comparison, and 
judgment, such ideas are absent in the lowest order of idiocy. Pro- 
found idiots have no idea of differences of persons or things. Higher 
idiots may be able to appreciate superficial resemblances and differences, 
especially of color and form, but the discernment is so faulty that 
incorrect inferences frequently result. 

Superior idiots appreciate resemblances more readily than differences. 
Simple generalizations may be possible, however, to all classes. In the 
lower types such generalizations occur only after long instruction, and, 
once this power is acquired, they may be fairly correct, but in many of 
the higher they are hasty and often faulty. In educable idiots, even 
those who can not talk, there is an appreciation of number, and they 
may be taught to count. Addition is more easily learned than subtrac- 
tion, and multiplication can only be learned by those with fairly 
developed memories. Division can rarely be taught them, and neither 
idiots nor imbeciles can understand problems. The superior orders of 
idiocy can count automatically, but rarely are able to do so with proper 
understanding. They can say two and two make four, four and four 
make eight ; but ask them how many are four and three and they are 
at sea. To count beyond ten, the number of the fingers, is rarely 
learned. But there are phenomenal instances where the mathematical 



IDIOCY. 883 

faculty is remarkably developed, as in the cases of the so-called 
"calculating boys," some of whom, it is true, are normal in other 
respects, but many of whom are mentally defective, belonging to the 
category of idiots or imbeciles. 

The idea of time, past and future, has seldom a place in the brain 
of the idiot. 

Ideas in the idiot are too feeble to be fixed ideas, and while the 
higher types are sometimes subject to morbid impulses, there is not a 
true fixed idea, with consciousness and pain. With them such ideas 
should rather be called tenacious ideas. 

The association of ideas occurs by resemblance, contrast, and con- 
tiguity. In the profound idiots, with few ideas, there may be an asso- 
ciation of them in a very simple way — viz., the sight of food is asso- 
ciated with the sensation of satisfied hunger, and so awakens the idea 
of eating. It is an association of sensations rather than of ideas. The 
association of ideas should arouse the critical faculty. The judgment 
and reason in idiots are very faulty. They are founded on an associa- 
tion of few ideas, lack precision and firmness, and find their expressions 
in ambiguous language. A judgment is not always the result of reason- 
ing. For reasoning, there must be some obstacle to an immediate con- 
clusion. Justice, promptitude, and firmness, which are qualities of 
judgment depending on the attention, are lacking in the judgments of 
idiots. The idiots judge very falsely on account of lack of attention 
and of an association of the simplest ideas. All their sense illusions 
give rise to false judgments. Firmness is lacking in their judgments, 
as they have so little interest in what they decide upon. 

Many imbeciles and feeble-minded, however, maintain their judg- 
ments with tenacity. They often have a very high opinion of their 
own intellectual faculties. This presumption leads them often to ex- 
treme blunders. If one of their judgments is admitted to be just, they 
become very proud of it, and immediately set to work to form others, 
which are generally absurd. Doubt which suspends action is rarely 
seen in any form of idiocy. The first impression capable of forming 
for them a judgment is followed immediately by the act, like a true 
reflex. Syllogistic reasoning does not occur either in idiots or imbe- 
ciles. Errors of the senses proceed from the perceptive apparatus 
rather than from the sensory apparatus. Since in idiots and imbeciles 
sense perceptions are retained in brain centers either undeveloped or 
diseased, and the memory pictures are consequently either confused or 
false, the association of these pictures is consequently faulty. In 
idiots, as the images are weak, the perceptive reasoning is also weak or 
wanting. In the imbecile, where the images are more numerous, the 
association may be falsified by a badly acting perceptive center. In 
him the association occurs so often by contiguity, and consequently the 
deduction is very liable to be erroneous, as contiguous ideas are not 
necessarily related ; hence, incongruous observations and unexpected 
actions. 

Sollier emphasizes the difference between idiots and imbeciles, which 
may be seen in the delirium sometimes occurring in these cases. 



884 MENTAL DISEASES. 

Exceptional in the idiot, when it occurs it is always in the impulsive 
form, unprovoked and without motive. It is a delirium of acts. In 
imbeciles there are attacks of maniacal excitement, with impulsion to 
kill, to set on fire, or to break. 

AVith respect to the production of ideas, there is little or none in the 
inferior types of idiocy, and in the higher grades the imagination is 
inchoate, of no utility, and often directed to things that are evil. 

Will, Personality, and Responsibility. — The elder Seguin looked 
upon defect of will as the basis of idiocy, but the will is rather a diffuse 
than a local function of the brain. It has no definite seat in the 
encephalon, lesion of which would impair or destroy it. As Sollier 
says, will in its simplest form is manifested by actions accomplished for 
the satisfaction of natural needs, appetites, and desires. Accordingly, 
the individual must have a consciousness of those needs. Such a con- 
sciousness may be very much blunted in profound idiots, and conse- 
quently the will will be almost entirely lacking. Such an idiot is a 
spinal being, and his movements may be compared to the reflex phe- 
nomena seen in decapitated frogs. In higher idiots, the will is mani- 
fested by more complex movements, which are, however, capable of 
becoming secondarily automatic. Voluntary control of the sphincters 
occurs only in idiots who learn to walk, and not until they have learned. 
Volitions do not exist in the lowest order of idiots. The most natural 
desires and the most primitive instincts are absent. The first to appear 
is desire for food, but it may manifest itself simply by a stretching 
out of the hand or a cry. In idiots in whom the will is more developed, 
and also in imbeciles, it finds its expression more easily in actions than 
in inhibitions. 

Self-respect, very little developed in the idiot, plays a very important 
role in the psychology of the imbecile, and by catering to it he can 
often be made to do things which would otherwise be impossible to 
obtain. 

Intellectual movements, or acts accomplished under the influence of 
judgment or reason, are infrequent in the idiot, and not common in the 
higher grades. Many idiots are incapable of choice. When the power 
of choice is present, it is often exercised with difficulty. He does not 
quickly understand that of two things he must take one and leave 
the other — he wants to take them both. It is the same with ideas. 
Between two desirable objects, the superior type does not hesitate, but 
takes without reflection the one he sees first, which he may wish to 
exchange when he sees the second. 

In idiots, whose will and motor volitions are so feeble, suggestion 
produces little or no results. It is the contrary in many imbeciles, 
except in those whose voluntary impulsiveness is too great. Ordinarily 
the higher grades are very susceptible to suggestion, as is seen by the 
facility with which mischief is done by a band of imbeciles which has 
been led on by one of their number. If suggestion is possible in 
imbeciles, it shows that the ideas which they already possess are very 
unstable, and are easily replaced by new ones. It has a great analogy 
with the suggestibility of the hysterical. 



IDIOCY. 885 

Consciousness and Personality. — As consciousness is but a phe- 
nomenon added to psychic processes, and not producing them, and as 
the personality is the coordination of psychic acts, it is necessary to 
form by deduction our conclusions as to these two attributes in the 
class of people we are studying. In absolute idiots it is not probable 
that any act is accompanied by consciousness. In higher idiots, in 
whom life is but little more than a succession of disconnected moments, 
it is not possible to say whether they have consciousness or not ; but the 
personality, if present, must be very rudimentary, since an essential 
of its existence is a proper appreciation of the continuity of events. 

For an individual to have consciousness of a psychic act, it is 
necessary that the exciting stimulus have a certain duration and inten- 
sity. Such factors in the stimuli are generally wauting in idiots ; and 
so it is probable that most of their psychic phenomena occur without 
consciousness ; and if there is consciousness, it must be very feeble. 
The distinction between the ego and the non-ego is not made by abso- 
lute idiots, and is but feebly present in the higher idiots. 

In many imbeciles consciousness may be wanting or feeble, but in 
some it is clearly present, together with a perfect idea of their per- 
sonality. Further, sometimes in delirium they have ideas of grandeur, 
showing an exaggerated conception of personality. 

Responsibility. — All lower types of idiots are unable to manage 
their own affairs or to enjoy their civil or political rights, but those of a 
higher degree, who are at liberty, may have these rights. 

Psychological Evolution. — In every degree of idiocy there comes 
a time, as Sollier well says, when the education stops and further mental 
progress ceases, and when the only hope is to retain the results which 
have been gained. This acme of development varies for the different 
psychic functions, so that one faculty may still improve, while another 
has already reached its cessation point. The senses continue to develop 
for the longest time, then the sentiments, and the intelligence the 
shortest. This is true of all classes, though the periods are longer in 
the higher grades, where all of the faculties are more equally and pro- 
portionally developed. Thus, in inferior types intellectual progress 
may cease at the age of six or seven, and the sentiments and senses con- 
tinue their development to eighteen or twenty, while in superior grades 
the improvement of senses, sentiments, and intellect may cease about 
the same time — viz., at puberty. 

Sometimes the faculties remain stationary, at others they retrograde 
when the limit of development is reached. Retrogression follows the 
same law as dementia — namely, progressive enfeeblement of will, intel- 
ligence, sentiments, and sensations, in the order named. AVhen retro- 
gression begins in the simpler forms it is very rapid, but in the higher 
types goes more slowly and more irregularly. Purely intellectual gifts 
which they have acquired (reading and writing) disappear very rapidly. 
In the intellectual downfall of the superior types one sees from time to 
time flashes of intelligence, like reflections from their weakening minds, 
but such are not observed in the lower forms. 

General Pathological Anatomy. — There has been accumulated in 



886 MENTAL DISEASES. 

literature of late years a great deal of valuable matter relating to the 
pathology and morbid anatomy of idiocy, so that much new light has 
been shed upon a somewhat obscure subject. The investigations of 
Sachs and myself x into the causation of the cerebral paralyses of chil- 
dren, which are so frequently associated with the various degrees of 
mental impairment, from feeble-mindedness to profound idiocy, and in 
which we found meningeal hemorrhage to be so commonly the primary 
lesion, might well give rise to the belief that in a majority of cases of 
idiocy without paralysis and in idiocy associated with epilepsy we are 
confronted with the same initial lesion. The site of the meningeal 
hemorrhage is the determining factor in the establishment of the symp- 
toms. If the Rolandic area be mainly implicated, either on one or on 
both sides, we have a hemiplegia or diplegia as the result, and these 
paralyses may be severe or light according to extent of the hemorrhage, 
and may be associated with idiocy or epilepsy, depending also upon the 
extent of the lesion and upon the amount of irritation. Again, I have 
seen a case in which there was left hemianopia, epilepsy, and very slight 
mental impairment, pointing to a meningeal hemorrhage over the right 
occipital lobe. Probably, too, some of the cases of arrested devel- 
opment of the speech, with or without enfeebled mind, are due to 
the same cause. It may be assumed also that meningeal hemorrhage 
often occurs as the initial lesion in what appears to be idiopathic epi- 
lepsy. The symptom or syndrome produced then will depend upon 
the location and extent of the initial lesion. Asphyxia at birth and 
convulsions shortly after birth are in themselves significant of menin- 
geal hemorrhage, and in our study of etiology we observe the great 
frequency of these symptoms in the history of idiocy. At our autop- 
sies, which are nearly always made years after the initial lesion, we 
find only terminal pathological states, such as atrophy, general sclerosis, 
and cysts, and, unfortunately, these conditions are not pathognomonic of 
antecedent hemorrhage, for they also are the terminal states for em- 
bolism, thrombosis, cerebral hemorrhage, meningitis, and meningo- 
encephalitis. What other evidence have we that proves the enormous 
preponderance of meningeal hemorrhage in the etiology of the terminal 
pathological conditions ? It is in the testimony of the investigators of 
the causes of still-birth. For instance, Litzmann 2 examined 161 still- 
born children, finding in them 35 cases of meningeal hemorrhage. Par- 
rot, 3 in 34 autopsies on the new-born, found 5 with blood in the arach- 
noid cavity and 26 with hemorrhage into the subarachnoid space. 

The study of Sarah J. McNutt, 4 of New York, in 1885, of 10 
similar cases added valuable testimony to that already given, and 
showed the relation between meningeal hemorrhage and asphyxia and 
convulsions in the new-born in a manner not to be gainsaid. 

lu The Cerebral Palsies of Early Life, Based on a Study of One Hundred and 
Forty Cases," "Jour. Nerv. and Ment. Dis.," May, 1890. See also paper on same 
subject by author, Louis Starr's ' ' Text-book of Diseases of Children, " Phila. , 1894, and 
Sachs' " Nervous Diseases of Children," New York, 1895. 
p 2 " Archiv fur Gyn.," Bd. xvi, 1880. 

3 " Clinique des Nouveau-nes, " Paris, 1877. 4 "Amer. Jour, of Obstetrics." 



IDIOCY. 



887 



Allusion is elsewhere made to Herbert K. Spencer's 130 autopsies 
in still-born children, in which there were 53 instances of hemorrhage 
from the pia and arachnoid. 

Thus, the evidence before us in favor of meningeal hemorrhage as 
the initial lesion in a large proportion of cases of idiocy is most con- 
vincing. Some idea of the character of the terminal states found in 
idiocy may be derived from the studies of Wilmarth 1 andBourneville. 2 
The former communicates the results of 100 autopsies, which he sum- 
marizes as follows : 

Sclerosis with atrophy, 12 ; sclerose tubereuse, 6 ; diffuse sclerotic 
change, 7 ; degenerative changes in vessels, ganglionic cells, or medul- 
lary substance, not constituting true sclerosis, 15 ; hydrocephalic, 5 ; 
general cerebral atrophy, 2 ; non-development in various forms, 16 ; 
infantile hemorrhage, 1 ; extensive adhesion of membranes from old 




Fig. 336. — Brain of a diplegic idiot, showing atrophy of the convolutions over large symmetrical areas 
— not a true parencephalia. (See history of case, " Proc. N. Y. Path. Soc," 1894, p. 94.) 



meningitis, 3 ; angiomatous condition of cerebral vessels (with degener- 
ative changes), 1 ; glioma (with sclerosis), 1 ; porencephalia (with 
non-development), 1 ; of 31 cases where actual disease or imperfect 
development of the brain proper was not demonstrated, there was 
hypertrophy of the skull, 6 ; acute softening (recent), 2 ; demimicro- 
cephalic, 2 ; when the brain was above usual weight, but the convolu- 
tions large and very simple in their arrangement, 2. 

Our examination of this summary discloses the fact that atrophies 
and diffuse sclerosis were demonstrated in 21 of the cases and tuberous 
sclerosis in 6. It is probable that the tuberous form of sclerosis has a 
pathology different from that of the diffuse form and more resembling 
the disseminated sclerosis of neuropathologists. Fifteen of Wilmarth's 
cases are recorded as presenting degenerative changes in vessels, gan- 

1 " Proceedings Ass'n Amer. Inst. Idiots and Feeble-minded," 1891. 

2 "Kecherches sur l'epilepsie, l'idiotie," etc., Paris, 1880-1897. 



888 MENTAL DISEASES. 

glionic cells, or medullary substance, " not constituting true sclerosis." 
There was evidently some resemblance to sclerosis, or this author would 
not have qualified his description thus ; and it is more than probable 
that the condition would have been pronounced one of genuine diffuse 
sclerosis by experts at the present day. Wilmarth notes 16 cases of 
non-development in various forms. He writes, in this connection : 

" Non-development is found in several forms. A portion of the 
cortical substance may be thin, and, instead of following the typical 
arrangement of the fully developed brain, form a number of irregular 
folds, which may be so small and numerous as to resemble a mass of 
angle-worms." 

This is evidently the condition which we know as microgyria, a true 
pathological process probably due to a vascular lesion (thrombosis or 
embolism), and not, therefore, a fault of development. Wilmarth's ob- 
servations were made, many of them, years ago, before neuropathology 
had attained its present precision, and hence have not the value of later 
researches, such as those undertaken at Bicetre and Upsala. 

Hammarberg x has made one of the most valuable contributions to 
the study of the pathology of idiocy in literature. His study enters 
into the details of the examination of the brains of nine cases of idiocy, 
imbecility, and feeble-mindedness. Several of these were epileptic and 
paralytic idiots. His pathological investiga tions were controlled by the 
microscopic examination of twelve normal brains. The results were 
briefly as follows : In all of the cases of idiocy a more or less large 
part of the cortex showed arrest of development at a stage correspond- 
ing to either an embryonal period or the period of early infancy. Only 
a small number of cells reached their higher development or were de- 
stroyed during the growth of the cortex. The mental defects were in 
direct proportion to the defects of the development of the cells, and 
were greater the earlier the period of arrest of development. 

As regards hydrocephalic idiocy, the true pathogeny of hydroceph- 
alus is unknown. It is generally explained as being due to a chronic 
intraventricular meningitis, a congestion of the ependyma. But in 
many of these cases nothing abnormal is observed about the ependyma 
save thickening. It is possible that a careful study of the manner of 
secretion of the cerebrospinal fluid and of the relations existing between 
the ependyma and the external serous membrane of the brain may 
help to elucidate the origin of the disorder ; for there is some reason for 
believing that a sort of current of fluid flows from the ventricles into 
the exterior serous cavity through the foramen of Magendie, the 
foramina of Mierzejewsky, and two other foramina which have been 
described, but are of uncertain existence. The ventricular walls secrete 
the cerebrospinal fluid and the exterior serous cavity absorbs it, accord- 
ing to this theory. Thus, then, there may be three processes by which 
primary hydrocephalus may be induced : hypersecretion in the ventric- 
ular spaces, occlusion of the foramina mentioned, and disorder of the 
absorbent apparatus. An interesting study of the subject along this 
line might be made. 

1 ' ' Stndien liber Klinik und Pathologie der Idiotie, " by C, Hammarberg, Upsala, 
1895 



IDIOCY. 



When the fluid begins to increase in the ventricles, these become 
dilated, as a rule equally, occasionally unequally, from obliteration of the 
foramen of Monro. The dilatation may be restricted to the lateral ven- 
tricles, or may include the third and fourth also. With the distention 
of the ventricles compression of the brain-substance takes place, giving 
rise to functional impairment of various kinds and degrees. With 
increase of pressure, atrophy of the compressed parts occurs. The 
septum between the ventricles may disappear and the brain-envelope 
become thin as paper, so that the hydrocephalus is like one enormous 



/ 







VV> 




Fig. 337.— Brain of a blind hemiplegic idiot. Atrophv and microgyria in both occipital lobes. (See 
history of case, " Proc. N. Y. Patb. Soc," 1894, p. 98.) 



cyst filling the cranial cavity. The basal ganglia and brain-stem 
become flattened. Examination of the cerebral envelope shows atrophy 
and degeneration of cells and fibers. The distention may go on until 
the cerebral tissues and the membranes vanish almost entirely. The 
amount of fluid has been known to reach six, eight, ten, twenty, and 
even twenty-seven pints. The following is an instance in point (a case 
from the Randall's Island Hospital for Idiots, the autopsy of which I 
reported at the New York Pathological Society. See " Proceedings/' 
1894, p. 94) : 

A female child, aged eighteen months ; hydrocephalus, whether 



890 MENTAL DISEASES. 

congenital or acquired unascertained. Circumference of head, 51.5 cm. ; 
anteroposterior diameter, 18 cm. ; greatest transverse diameter, 15 cm. ; 
naso-occipital arc, 32 cm. ; binauricular arc, 34 cm. 

Blindness and nystagmus ; widely gaping fontanels ; spastic di- 
plegia ; occasional convulsions, and just before death opisthotonos. 
At the autopsy sixty-four ounces of reddish serum were first removed 
by tapping the anterior fontanel. The skull and dura were exceed- 
ingly thin. The falx cerebri had disappeared. Cutting through the 
thin dura, nothing was to be seen of any brain proper in the great cavity 
of the head. The membranes usually covering the cerebrum had dis- 
appeared with that organ. At the base of the skull the floors of the 
ventricles and basal ganglia stood out prominently, and back of these 
parts, lying on the tentorium, were the only vestiges of a cerebrum — 




Fig. 338. — Brain and skull in a case of hydrocephalus. 

parts of the two occipital lobes. On removing the tentorium, the cere- 
bellum was found to be of about normal size. Microscopical exami- 
nation showed degeneration and atrophy of the lateral columns of the 
cord (Fig. 338). 

In this case, then, we have to do with distention and atrophy of the 
encephalon pushed to its greatest extreme. 

Case IV, in a series of autopsies by Bourneville, is a good illustra- 
tion of the nature of the process of compression and atrophy. A girl, 
a complete idiot, died at the age of about two years. Five hundred 
grams of fluid were found in the brain-cavity, the brain-envelope 
having become merely a sac of varying thickness. For instance, in 
the right hemisphere, over the whole of the temporo-occipital region, 
the wall of cerebral substance was but a millimeter in thickness, and 
at one place here, near the fissure of Sylvius, the brain-substance was 



IDIOCY. 891 

absent altogether at a space of four centimeters in diameter, closed 
merely by a fine meningeal veil. In this case, then, the process of 
complete atrophy of the brain was arrested by death. 

As the ventricular cavities dilate, pushing the brain-envelope with 
them, the skull-cavity is distended and the cranial bones are separated, 
made thinner, and expanded in area. The enlargement of the head is 
directly proportional to the youth of the patient. Cases beginning be- 
fore or shortly after birth will present greater expansion of the 
cranial cavity than such as have a later origin. Sometimes some 
sutures give way and others become synostosed. Where sutures are 
separated Wormian bones often form, or a membranous connection is 
established between the cranial bones. 

Occasionally, in these cases of primary hydrocephalus, the defects of 
brain-substance are not due to pressure-atrophy, but there is an associ- 
ated condition of malformation or defect. Thus, in an autopsy of 
Bourne ville's, on a girl about thirteen years of age, with congenital 
hydrocephalus, idiocy, and epilepsy? the hemispheres of the cerebellum 
were totally absent, the cerebellum being represented by the vermis, 
which was the size of a pigeon's egg. Perhaps such a defect is due to 
a pressure-atrophy beginning very early in fetal life. 

As regards the pathology of secondary hydrocephalus, we possess more 
definite knowledge. In this the internal hydrocephalus is caused by ob- 
struction of the veins of Galen, or by obliteration of the foramina of 
Monro, Magendie, or Mierzejewski. Common causes are tumors of 
the cerebellum, such as sarcomata and tubercles. Meningitis may act 
in the same way. The amount of hydrocephalus, ventricular dilatation, 
and expansion of the skull thus induced will depend directly upon the 
youth of the infant or child. As a rule, secondary hydrocephalus never 
reaches the extent of the primary form, owing to the rapidly fatal nature 
of its cause. In these cases we seldom see pressure effects beyond flat- 
tening of the convolutions and moderate expansion of the cranial vault. 

An exceptional and an extremely interesting case was one upon whom 
I made an autopsy at Randall's Island, not long ago. It was a case of 
very marked hydrocephalus in a child of four years, in which a small 
tumor of the pineal gland, the size of a small hazel-nut, compressed 
and obliterated the aqueduct of Sylvius. Both of the lateral ventricles 
were enormously distended, the left more than the right, and contained 
twenty-four ounces of clear fluid. The third ventricle Avas also widely 
dilated. The fourth ventricle was of normal size. Microscopical sec- 
tions of the quadrigeminal region revealed the obliteration of the aque- 
duct. The tumor was apparently tubercular, but was not examined, it 
having been mislaid and lost. 

The cases of acute hydrocephalus due to meningitis serosa, and the 
cases in which a defect of brain-substance is counterbalanced by an equal 
bulk of cerebrospinal fluid, do not commonly fall under this heading. 

In chronic hydrocephalus internus there seems to be a special sus- 
ceptibility of the membranes to acute disease, so that at autopsy it is 
not uncommon to find evidence of an acute meningitis, simple, hemor- 
rhagic, suppurative, or tubercular. 



892 



3IEXTAL DISEASES. 



The fluid found in hydrocephalic idiots has been frequently analyzed. 
In a case of Bourneville's the analysis of the hydrocephalic fluid, with- 
drawn nine hours after death, resulted as follows : Color, pale yellow ; 
aspect, clear after standing ; reaction, neutral ; odor, like that of blood ; 
consistence, slightly viscous; density, 1.006; organic matter, 1.65; 
salts, 10; total fixed solids, 11.65; phosphoric acid, 0.22; sodium 
chlorid, 0.80; albumin, 0.26; leukocytes, very few; red blood-cor- 
puscles, considerable. 

In microcephalic idiocy we recognize three distinct classes : 

1. Morphological microcephaly, in which there are no pathological 
changes in the brain, but simply a brain arrested in its development 
with persistent fetal morphology. 

2. Pathological microcephaly, in which the small size of the head 
is determined by morbid processes in the brain (such as meningeal hem- 
orrhage, thrombosis, porencephalic defects, etc.). 

3. Mixed cases of microcephaly, in which pathological processes are 
superadded to or associated with true morphological microcephaly. 

The following table gives a summary of the pathological conditions 
responsible for most cases of idiocy : 



Etiological Factors. Primary Lesions. 


Terminal Conditions Found 
at Autopsy. 


Hereditary degeneracy. 


Developmental defects of 
portions of the brain, 
such as corpus callosum, 
one hemisphere or part 
of a hemisphere. 


Same, with compensatory 
hydrocephalus internus, 
extemus, or both : com- 
pensatory thickening of 
skull. 


Hereditary degeneracy. 


Micrencephalus, with or 
without defects. 


Same. B r a i n-substance 
often sclerotic ; deficient 
in microscopical ele- 
ments. Sometimes com- 
pensatory hydrocephalus. 


Hereditary degeneracy. 


Agenesis corticalis ; slight 
changes in gross appear- 
ance of brain ; maldevel- 
opment of microscopical 
elements. 


Same. Sometimes hydro- 
cephalus externus. 


Vascular disorders of fetal Partial defects like poren- 
brain. cephalia, microgyria. 


Same. Compensatory hy- 
drocephalus and thicken- 
ing of the skull ; atrophy 
and sclerosis of affected 
convolutions or lobes. 


Diseases of mother or trau- 
ma to mother. 

Fetal disorders, such as 
syphilis, asphyxia at 
birth, prolonged labor, 
infantile convulsions, 
febrile diseases of child, 
cerebral diseases of child. 


Meningeal hemorrhage ; 
thrombosis ; embolism ; 
cerebral hemorrhage ; 
meningitis ; meningo- 
encephalitis. 


Atrophy ; diffuse sclerosis ; 
cysts ; meningoencepha- 
litis. 


Uncertain fetal and post- Tumor sometimes ; oftener 
natal causes. unknown. 


Hydrocephalus. 


Antecedent infectious dis- Tuberous sclerosis, 
eases of mother or child (?) . 


Tuberous sclerosis. 



IDIOCY. 893 

In amaurotic idiocy but six autopsies have been made, and thus far 
the changes found may be considered to be simply degeneration of the 
gray matter of the cortex and of the anterior horns of the cord 
(Sachs). 1 

Diagnosis and Prognosis of Idiocy. — Diagnosis of Idiocy in 
General. — It is seldom difficult to make a diagnosis of idiocy in child- 
hood when the individual has reached such a stage of development 
that backwardness and deficiency stand out in prominent contrast to 
the normal average of intelligence in children of the same age. Occa- 
sionally, however, we have to deal with some species of insanity in 
childhood, in which case the matter of diagnosis is important because 
of the more favorable outlook for insanity. There are not a few pa- 
tients cared for in institutions for the feeble-minded and idiots in which 
insanity has been the original factor in the mental impairment, and 
when the histories of such are obscure, it is almost impossible to dis- 
tinguish between ordinary idiocy and what may be truly termed a ter- 
minal dementia following upon some acute insanity of childhood. In 
these cases residual symptoms of a psychosis can be our only guide. 

The diagnosis of some form of idiocy in infancy is far from easy 
unless one familiarizes himself thoroughly with the manifold steps of 
development for the first few years of existence. Early diagnosis is 
of the utmost importance, not only for the benefit of the unfortunate 
child itself, but on account of the deep solicitude of the parents for its 
future. One of the chief aids in differentiation will be found in a 
study of the physical condition of the infant. The shape and size of 
the head should be carefully noted and compared with normal shapes 
and statistics. Unfortunately, there are no elaborate tables of head 
measurements in infants and children as yet made which can be looked 
upon as a final establishment of the normal averages, but the following 
figures are fairly representative of cranial measurements : 

Circumference at birth 36 cm. in both sexes. 

Binauricular arc 22 " " " " 

Naso-occipital arc 22 " " " " 

At the age of one year these dimensions have increased to — 

Circumference . 44 cm. in both sexes. 

Binauricular arc 27 " " " " 

Naso-occipital arc 30 " " ' l " 

Malformation and asymmetry of the head should be taken into con- 
sideration. The various malformations are treated of in another chapter. 
The presence of marked anatomical stigmata of degeneration is of sig- 
nificance. Paralysis of a limb or limbs, if of cerebral origin, is of great 
importance, indicating, as it does, some lesion of the brain, w T hich may 
retard or restrict mental development and lead to paralytic or epileptic 
idiocy, or both. Some of the morbid movements, such as nystagmus, 
ataxia, chorea, or athetosis, may be present, and, as symptoms of dis~ 

1 " A Case of Amaurotic Family Idiocv with Autopsv," by Frederick Peterson, 
M. J)., " Jour. Xerv. and Ment. Dis.," July, 1898. 



894 MENTAL DISEASES. 

order of the central nervous system, should lead to a careful investi- 
gation of the whole mental and physical organization. 

While it is frequent to find evidence of idiocy immediately after 
birth in bodily and especially in cranial and facial characteristics, yet 
after careful examination as to imperfect action of the sensations and 
perceptions, we may sometimes recognize idiocy in cases where physical 
evidence is wanting. The child may not learn easily to take the breast. 
Its cry is different from that of other children. It cries without 
motive. Sometimes there is congenital blindness or congenita] deaf- 
ness. In the normal child the sense of smell may be stimulated imme- 
diately after birth, and taste is evident on the first day. In the idiot 
these special senses may be retarded in their development or absent. 
The movements of the eyes are generally irregular, and strabismus is 
frequent until the end of the second month in normal children, so that 
in the diagnosis of idiocy this cannot be relied upon as significant unless 
the eye-movements are imperfect after the third month. In the normal 
child the eyes follow a light between the third and fourth weeks ; in 
idiots this aoility may be retarded indefinitely. The normal child starts 
at gentle touches on the day of birth. The new-born idiot may be im- 
mobile or feeble in its reactions to cutaneous stimuli. The normal child 
laughs at tickling in the eighth week, while the idiot or imbecile is not 
incited to laughter ordinarily at all in the earliest years of life. From 
these facts it follows that in defectives we must examine the sensory 
organs themselves, so far as possible, for defects, as well as study their 
reactions and impaired perceptions of sensations. 

Preyer, in his work on " The Mind of the Child," gives a conspectus 
of the development of the normal faculties during the first forty months 
of the child's life, and the following brief abstract is made therefrom for 
purposes of comparison with the mental development of the idiot. This 
abstract has been modified, however, by comparison with the many stud- 
ies of child development made since Preyer's time, and particularly in 
regard to the development of the senses in the light of the study of 1060 
new-born babes at the New York Lying-in Hospital, by Miss Kainey 
and myself, during the year 1910. (See " Bulletin of the New York 
Lying-in Hospital," 1911.) 

NORMAL CHILD. 

First month. — Sensitive to light at birth. Pleasure in light of candle 
and in bright objects on eleventh day. Hears at birth. Discriminates 
sounds last two weeks of month. Starts at gentle touches at birth. Sen- 
sibility to taste at birth. Strong-smelling substances produce mimetic 
movements at birth. 

Pleasure first days in nursing, in bath, in sight of objects. 

Discomfort first days from cold, wet, hunger, tight clothing. 

Smiles on twenty-sixth day. 

Tears on twenty -third day. 

Vowel-sounds in first month. 

Memory first active as to taste and smell ; then as to touch, sight, 
hearing. 

Incoordinate movements of the eyes. Fixation may occur in second week. 



idiocy. 895 

Sleeps two hours at a time, and ordinarily twenty hours in twenty- 
four (Lying-in Hospital Report). 

Reflexes active. 

Second Month. — Strabismus occasional until end of month. Recog- 
nizes human voices ; turns head toward sounds. Pleased with music 
and with human face. Sleeps three, sometimes five or six, hours. 
Laughs from tickling at eighth week. Clasps with its four fingers at 
eighth week. First consonants from forty-third to fifty-first days 
(am-ma, ta-hu, go, ard). 

Third Month. — Sixty-first day, cry of joy at sight of mother and 
father ; eyelids not completely raised when child looks up. Accommo- 
dates at ninth week. Notes sound of watch at ninth week ; listens 
with attention. 

Fourth Month. — Eye-movements perfect. Objects seized are moved 
toward the eyes. Grasps at objects too distant. Joy at seeing self in 
mirror. Contraposition of thumb in grasping at fourteenth week. 
Head held up permanently. Sits up with back supported at fourteenth 
week. Beginning to imitate. 

Fifth Month. — Discriminates strangers. Looks inquiringly. Pleas- 
ure in crumpling and tearing newspapers, pulling hair, ringing a bell. 
Sleeps ten to eleven hours without food. Desire shown by stretching 
out arms. Seizes and carries objects to mouth. Consonants / and h. 

Sixth Month. — Raises self to sitting posture. Laughs, and raises 
and drops arms when pleasure is great. " Crows " with pleasure. Com- 
pares image of father in mirror with original. 

Seventh Month. — Astonishment shown by open mouth and eyes. 
Recognizes nurse after four weeks' absence. Sighs. Imitates move- 
ments of head, of pursing lips. Averts head as sign of refusal. 
Places himself upright on lap. 

Eighth Month. — Astonishment at new sounds and sights ; at imita- 
tions of cries of animals. 

Ninth Month. — Stands on feet without support. More interest 
shown in things in general. Strikes hands together with joy. Shuts 
eyes and turns head away when something disagreeable is to be en- 
dured. Fear of dog. Turns over when laid face downward. Turns 
head to light when asked where it is. Questions understood before 
child can speak. Voice more modulated. 

Tenth Month. — Sits up without support in bath and carriage. First 
attempts at walking at forty-first week. Beckoning imitated. Missed 
parents in absence, also a single ninepin of a set. Can not repeat a 
syllable heard. Monologue and hints at imitation (ma, pappa, tatta, 
appapa, baba, tatti, pa, rrrr rrra). 

Eleventh Month. — Screaming quieted by " sh." Sitting becomes 
habit for life. Stands without support. Stamps. Syllable correctly 
repeated. Whispering begins. Consonants b, p, t, d, m, n, r, I, g, Jc, 
vowel a most used, u and o rare, i very rare. 

Twelfth Month. — Pushes chair. Can not raise self or w T alk without 
help. Obeys command, " Give the hand." 

Thirteenth Month. — Creeps. Shakes head in denial. Says papa 
and mamma. Understands some words spoken. 



896 MENTAL DISEASES. 

Fourteenth Month. — Can not walk without support. Raises himself 
by chair. Imitates coughing and swinging of arms. 

Fifteenth Month. — Walks without support. Laughs, smiles, gives 
a kiss on request. Repeats syllables. Understands ten words. 

Sixteenth Month. — Runs alone. Falls rarely. 

Seventeenth, Eighteenth, and Nineteenth Months. — Sleeps ten hours 
at a time. Associates words with objects and movements. Blows 
horn, strikes with hand or foot, gives leaves to stag, waters flowers, puts 
stick of wood in stove, washes hands, combs and brushes hair, and 
other imitative movements. 

Twentieth to Twenty-fourth Month. — Marks with pencil on paper, 
whispers in reading newspaper. Very few expressions of his are recog- 
nizable. Executes orders with surprising accuracy. Tries to sing and 
beat time, and dance to music. 

Twenty-fifth to Thirtieth Month. — Distinguishes colors correctly. 
Sentences of several words. Begins to climb and jump and to ask 
questions. 

Thirtieth to Fortieth Month. — Goes upstairs without help. Sen- 
tences correctly applied. Clauses formed. Words distinctly spoken, 
but influence of dialect appears. Questioning repeated to weariness. 
Approximates manner of speech to that of family more and more. 

By contrasting the mental development of the supposedly abnormal 
child with these observations upon normal development, it will not be 
difficult to appreciate impairment of varying degree. The presence of 
mere backwardness may not infrequently, however, be observed in chil- 
dren that later develop normally, and it is well to bear this fact in mind ; 
but the combination of backwardness in the development of the sen- 
sations, perceptions, ideation, and speech with marked physical signs of 
degeneracy or brain lesion would be naturally of the greatest importance 
from the diagnostic point of view. 

Diagnosis of the Form and Nature of the Idiocy. — While the 
diagnosis of the presence of idiocy is, as a rule, fairly easy, especially 
after infancy has reached the stage of childhood, the diagnosis of the 
type or kind of idiocy presented is often attended with great difficulty. 
Where the cerebral disorder or defect is accompanied by striking physi- 
cal peculiarities or malformations, such as hydrocephalus, microceph- 
aly, paralysis, or myxedema, we are immediately in a position to 
classify the type. In idiocy associated with epilepsy, too, we can readily 
approximate the type, though it must always be remembered that there 
are three distinctive ways in which epilepsy and idiocy are correlated — 
viz., paralytic idiocy combined with epilepsy, epileptic idiocy from a 
homologous lesion not implicating the motor centers or tracts, and, 
finally, dementia in childhood depending upon the epilepsy. The trau- 
matic class of cases is recognized either by the external evidence of in- 
jury to the skull or by the history of direct relation of the psychic 
symptoms to the antecedent trauma. The sensorial type of idiocy is 
distinguished by existing or foregone loss of two or more senses, par- 
ticularly blindness and deafness. The amaurotic type presents a char- 
acteristic syndrome — viz., flaccid or spastic weakness or paralysis of the 



IDIOCY. 897 

whole musculature, diminished or exaggerated tendon-reflexes, dis- 
tinctive changes in the fundus leading to optic atrophy, and marasmus. 
In the majority of cases, then, we are in a position to determine readily 
the form of idiocy presented by the patient and to formulate an opinion 
as to the nature of the pathological process or the condition underlying 
it ; but there will still remain a considerable number of cases in which 
diagnosis can not be made during life, either as to the type of idiocy 
before us or as to the character of the process. Among such puzzling 
cases will be those indistinguishable from the psychoses of early life ; 
idiocy following meningeal hemorrhage and meningitis without inducing 
either paralysis or epilepsy ; idiocy due to tuberous sclerosis, and the 
like. 

Diagnosis of the Degree of Idiocy. — It is necessary, for purposes 
of medicopedagogical treatment, to comprehend the degree of idiocy, 
not only to determine whether it is simple idiocy, imbecility, or feeble- 
mindedness, but to ascertain, as far as possible, the different shades of 
each of these ; and it is useful, too, to watch the progress of a case under 
treatment, and to record from time to time the advance made by the 
patient and pupil. Accordingly, the writer has drawn up what may be 
termed a species of mind chart, as given opposite. The physician will be 
familiar with the ordinary tests for common and special sensibilities. 
The intensity and duration of attention may be studied, in the same 
connection, by methods which will readily suggest themselves in relation 
to objects, colors, sounds, smells, and tastes, which are utilized in such a 
way as to demonstrate perception, the retention of the perception, and 
the duration of such retention. The chief difficulty will be in deter- 
mining and recording the purely intellectual features of the case ; but 
some patience and perseverance will demonstrate the ability and degree 
of ability of the patient to acquire, conserve, associate, and produce 
ideas, concrete and abstract ; to appreciate resemblances and differences ; 
to count, add, subtract, and divide. 

Prognosis. — As regards the cure of idiocy, there can not be any 
difference of opinion. There are few cases — indeed, almost no case — in 
which improvement to some degree may not be promised under proper 
conditions ; but cure there is none. The profound idiot may be regen- 
erated to some slight degree ; be made less repulsive, less offensive, less 
destructive. The imbecile can be taught cleanliness, speech, divers 
occupations. The feeble-minded subject is susceptible of enormous im- 
provement. It is impossible in any case to predict how much advance 
may be made under the best supervision, but it will be safe to say that 
the methods now in vogue in the training of the idiot will surprise the 
relatives or guardians by their efficacy, and there is no case so unprom- 
ising and hopeless as to contraindicate an attempt at improvement 
Left to itself, even a mild type of idiocy will not only make no prog- 
ress, but will be certain to degenerate, to lapse into a lower grade. 
Shuttleworth, l in reviewing the results of twenty years' experience at 
one of the large English institutions, states that of patients discharged 

1 Tuke's "Dictionary of Psych. Med.," p. 675. 
57 



898 



MENTAL DISEASES. 



Sex., 



Mind Chakt. 

Name Ag e 

Constitution (feeble, fair, robust, or obese) 

Form of idiocy Degree of idiocy 

Paralysis, deformity, or morbid movements 

Right- or left-handed Temperament (cheerful, gloomy, restless, 

sluggish, etc. ) 



Sense 
defects. 


Sight. 


Hearing. 


Taste. 


Smell. 


Tactile 
and pain. 


Muscu- 
lar. 


Ther- 
mic. 


Intensity 
and duration 
of attention. 
















Instincts. 


Hunger. 


Self-pres- 
ervation. 


Sleep. 


Voluntary 
move- 
ments ; 
play. 


Sexual. 


Imita- 
tion. 




Morals and 
Habits. 


Tidiness. 


Destruc- 
tiveness. 


Human- 
ity. 


Veracity. 


Polite- 
ness. 


Obedi- 
ence. 




Sentiments. 


Pleasure 
and pain. 


Affec- 
tion. 


Fear. 


Anger. 


Acquisi- 
tiveness. 


Shame. 


Curios- 
ity and 
astonish- 
ment. 


Language. 


Speech. 


Reading. 


Writing. 


Gesture. 


Drawing. 






Intellect. 


Ideas. 


Memory. 


Associa- 
tion of 
ideas. 


Reason. 


Judg- 
ment. 


Will. 


Arith- 
metic. 



Special aptitudes . 



idiocy. 899 

therefrom after full training, 10 percent, became self-supporting, another 
10 per cent, might have become so had they obtained suitable situations, 
and about 20 per cent, were reported as useful to their friends at home. 
This bears out the earlier estimate of Seguin, who said that " more than 
40 per cent, have become capable of the ordinary transactions of life 
under friendly control, of understanding moral and social abstractions, 
of working like two-thirds of a man ; and 25 to 30 per cent, come 
nearer and nearer the standard of manhood, until some of them will defy 
the scrutiny of good judges, when compared with ordinary young men 
and women." 

There are certain features in connection with the different types of 
idiocy which are helpful in forming our opinion as to the probable 
future of a patient. For instance, it may be taken as an axiom that 
the greater the defect or injury of the brain, the profounder will be the 
mental impairment and the more difficult will be the labor of bringing 
about an amelioration of the condition. The earlier, too, that the brain 
is hampered in its development, the worse, as a rule, is the prognosis. 
This holds good for every form of idiocy. Hence the outlook for the 
congenital types is less promising than that for the acquired, and for 
idiocy acquired in the first year less than that for idiocy acquired in the 
second. Some of the prognostic indications of the special forms will 
be discussed under their respective captions ; but, in general, it may 
be assumed that microcephalic idiocy and congenital hydrocephalic 
and paralytic idiocy will be benefited least among the types of idiocy 
discussed, and always in proportion to the intensity of the morbid pro- 
cess. The sensorial, traumatic, and myxedematous forms are, ceteris 
paribus, among the most promising. The amaurotic form is generally 
fatal. Idiots with special aptitudes, or idiots savants, tend to early 
psychic degeneration. Idiots that are extremely restless, as shown by 
incessant motion of the hands, arms, head, trunk, or by constant walk- 
ing, are generally among the most intractable, because of the difficulty 
of fixing their attention. 

Although there is scarcely ever to be encountered an idiot in whom 
improvement of some kind can not be brought about by assiduous cul- 
tivation of whatever residual faculties and functions he possesses, it is 
practically necessary to classify idiots into teachable and unteachable. 
It is practically so because a majority of these defectives are found 
among the poor, who can not command all that the world affords in the 
way of treatment, care, and training. INor could the commonwealth 
assume the enormous task of doing the best for all its idiot charges. No 
community could possibly be repaid for any such undertaking, because 
the idiots classified by public authorities as unteachable are not sus- 
ceptible of such development as would satisfy the tax-payers' right to 
ask the utility of the expenditure. It is only with private families that 
anxious parental solicitude will and can demand that medicopedagog- 
ical care, skill, and patience which can surmount almost insuperable 
difficulties in the education of profound idiots. Practically, therefore, 
we find that there is a tendency to separate idiots into the teachable 
and unteachable ; a tendency in our public institutions to exclude un- 



900 MENTAL DISEASES. 

promising cases, such as epileptic and paralytic idiots, idiots with mal- 
formations, marked cases of hydrocephalus and microcephaly, and, indeed, 
any patient requiring that particular and assiduous care which it is not 
in the power of the commonwealth to give. 

The prognosis as regards life depends directly upon the degree of 
injury to or defect of the brain. In general, idiots are short-lived. 
Diplegic and paraplegic idiots seldom attain the age of twenty years ; 
hemiplegic idiots may live much longer, though it is infrequent for 
them to attain the age of forty and more years ; hydrocephalics perish 
still earlier. The same is true of profound cases of microcephalic and 
myxedematous idiocy. The rare form known as amaurotic idiocy is 
almost invariably fatal in infancy. 

General Treatment of Idiocy. — The treatment of the idiot in- 
volves the employment of both physician and teacher. The adjective 
medicopedagogic is made use of to designate this combination of medi- 
cal and educational features for the care of the defective classes. In 
the union of the two professions for such purpose the educator occupies 
relatively the higher and more important position. The inestimable 
services of trained care-takers or nurses are not to be overlooked. That 
patient will profit most who receives the properly combined aid of the 
best physician, best teacher, and best nurse. As a rule, this fortunate 
concurrence of necessary aids is more apt to be found in the public or 
private institution than in the home ; but that it is possible to carry on 
treatment at home under favorable circumstances, is not to be gainsaid. 

The methods of procedure formulated by Itard, expanded by Seguin, 
and employed now-a-days everywhere in private and public institutions 
for idiots, with modifications induced by experience and the progress 
of educational science, are well described in the writings of Bourneville, 
Shuttleworth, Ireland, Down, and others. A brief resume is given 
below of the process of 

Education of Idiots. — The educational treatment should begin as 
soon as the diagnosis of defective intelligence is made. It need not be 
pushed vigorously at too early an age ; but infancy, when the nervous 
system is most impressionable, plastic, and pliable, is the time for easy 
modification and the bringing out of the rudimentary psychic processes 
which are the foundations for the later conduct, habits, intelligence, 
and speech. Patients are admitted to the Bicetre and Salpetriere at 
the age of two years and over. 

In order to understand the methods of pedagogic treatment of idiocy, 
let us imagine an infant brought before us afflicted with a profound degree 
of idiocy — L e., one showing little or no attention, unable to walk, to use 
its hands or to speak, and uncleanly in habits. In undertaking a case 
of this kind the process of education is pursued with the following dis- 
tinct purposes in view : 

1 . To develop the attention and sharpen the five senses. 

2. To develop coordinated movements and strengthen the muscles. 

(a) To teach to walk. 

(b) To teach use of the hands. 

3. To inculcate habits of cleanliness in person and dress. 



IDIOCY. 901 

4. To teach the patient the use of language. 

5. To arouse the intellect by inculcating ideas of length, weight, surface, solids, 

form, number. 

6. Finally, to carry the education higher, by means of studies in natural history and 

all sorts of manual and industrial and moral training. 

Naturally, some of these purposes are attained at the same time to 
a considerable degree by some one process employed in education. 
Thus, when a light bean-bag is thrown at the face of our patient, the 
attention and sensibility may be so feeble that it is not noticed at first. 
By frequent repetition attention is developed, sensibility becomes more 
acute, a reflex movement to ward off the missile is aroused, and gradu- 
ally, by successive stages, the patient learns to catch the bag, to throw 
it back, and, finally, to go through a simple drill with it, accompanied 
by music. This single experiment then improves the attention and 
several of the senses, and aids in developing coordination and strength 
of the muscles. 

Attention. — The degree of attention is, in the idiot, an indication 
of the degree of idiocy. To a certain extent the degree of attention 
noted is of value in prognosis ; for, if the attention can not be aroused 
at all, no progress in education can be made. Thus the first step in 
our process of education must be the employment of methods of excit- 
ing attention. The most useful are such as appeal to cutaneous sensi- 
bility, to the eye, and to the ear. But even if these are in abeyance, 
the other senses afford useful avenues of approach to the nervous 
centers. Pricking, tickling, light blows, hot and cold articles, etc., 
may be used to attract attention through the skin. Colored balls, 
brilliant pieces of cloth, a ray of light in a dark room, the magic 
lantern, or a spectrum — such things may be variously and patiently 
experimented with to fix the attention of the eye. A loud call, a bell, 
music, a gong, or even a pistol shot sometimes, are devices for exciting 
the attention of the ear. Not infrequently months of patient experi- 
ment must be traversed before we are rewarded for our labors. 

Education of the Sense of Touch. — The methods in vogue for 
developing the sense of touch generally aid at the same time the coordi- 
nation of muscular movements ; hence in actual practice the education 
of the hand and touch and also of the eye proceed more or less simul- 
taneously. 

The idea of temperature is developed by plunging the hand into cold, 
tepid, or warm water, or by the application of bottles containing water 
at different temperatures. 

The sense of smoothness or roughness of surface is inculcated by 
passing the finger-tips over a board, one-half of which is covered with 
velvet, the other half roughened like a grater. Pieces of stuff of vary- 
ing degrees of roughness or smoothness are also made use of. The 
softness and hardness of objects are taught by the handling of different 
objects, such as hard balls or cushions. 

The child is taught to button by means of two bands of cloth, one 
with large buttons and the other with large button-holes ; to lace up a 
shoe, by means of a shoe with eyelets a centimeter in diameter, and 



902 MENTAL DISEASES. 

alternately hemmed with red and blue leather ; to tie knots, with the 
aid of a pad upon which are spread strings of divers colors. 

Stringing beads and buttons, sticking pins into a pincushion covered 
with dotted stuff, and the use of the size-board and form-board are 
useful means of developing tactile sense, educating the eye, and bringing 
out some of the faculty of calculation. 

The Education of the Eye. — After the physician has remedied any 
existing visual defects, it becomes the duty of the instructor to interest 
the restless and inattentive eye. As already mentioned, the attention is 
aroused by glittering and striking objects, and, once the gaze is captured, 
the latent sense may be drawn out by many devices familiar to the 
kindergartner and teacher. Particolored balls, variegated shapes and 
colors of blocks, spheres, squares, cubes, illuminated pictures, gaudy 
stuffs, the spectrum, the kaleidoscope — all of these play a role in the 
education of the vision of the defective pupil. The matching of 
ribbons, wools, or cards, and the discrimination of forms of blocks, are 
methods of aiding the higher development of the visual sense. The 
size- and form-boards already alluded to, and the use of graduated rods 
to be placed by the pupil in step-like rows, are excellent adjuncts. 
Later on come into play various games, — dominoes, ball, croquet, mar- 
bles, bean-bag, hoops, tennis, skipping, battledore and shuttlecock, quoits, 
golf, and the like, — in the employment of all of which not only is the 
vision stimulated and improved, but there is a gain in manual dexterity, 
and an associated development of some of the psychic functions. The 
teacher acquires a special tact in leading the pupil to concentrate his 
mind upon what is being done, and in making use of the instinct of 
imitation, so that the child endeavors to do as the other pupils are doing 
or to follow the movements of the instructor. 

Education of the Sense of Hearing 1 . — After the physician has 
made sure that defective hearing is due rather to want of attention than 
to any of the many causes of deafness, the teacher experiments upon 
the sense with sounds of various kinds — gongs, bells, speech, instru- 
mental music, and songs — and by some one of these means the ear will 
at last be reached and kept open until it becomes an avenue for im- 
pressions from the environment to travel to the brain for registration and 
the rousing of new cerebral activities. This organ in the defective is 
often especially alive to the influences of melody and harmony, to songs 
and jingles and rhymes. Music is an efficient aid in the various drills 
and games made use of later on in the child's mental development. 

Education of the Taste and Smell. — While these senses have 
not the importance of the three just described, it is still useful to 
stimulate and develop them as far as possible. The child can be taught 
to discriminate between the simple taste sensations — salt, sweet, bitter, 
and sour — by means of solutions of salt, sugar, quinin, and citric acid, 
and between odors that are noisome and odors that are pleasant by 
means of tinctures of asafetida, cloves, and musk, and divers perfumes. 
Later, he learns to distinguish flavors, and to associate what is good 
and useful with pleasant, and what is hurtful with noxious tastes and 
smells. 



IDIOCY. 903 

Teaching to "Walk. — A course of light massage of the lower ex- 
tremities, together with exercise of the joints in flexion and extension, 
is undertaken for the purpose of developing suppleness and strength and 
improving the nutrition. The child is then regularly placed in a swing 
constructed for the purpose, with a vertical board in front in such a 
position as to receive the advancing feet of the child as it moves to and 
fro. The impact of the feet upon the board, with the backward swing 
caused thereby, in the course of time gives the child a sort of pleasure, 
and awakes in it a sense of the dependence of its movement upon the 
varying pressure and impact of its feet. It is not long before the child 
is enabled to use its legs with considerable ease and skill in the exercise. 
Having attained this stage, the child is now frequently held upright on 
its feet and then placed between the parallel bars sustained by its arms, 
in which position it is induced to make efforts at walking, at first for a 
few minutes, but with gradual increase of the time of stay each day. 
Then the pupil becomes quickly ready for a wheel-chair, which is merely 
a modification of the principle of the parallel bars, the supports being 
on wheels, so that as the child walks it moves the apparatus about with 
it. Later on it is taught to mount and descend a stair by means of a 
short, stationary step-ladder. After this the gait is rapidly improved 
by a variety of exercises, drills, simple dances, and the like. 

Education of the Hands. — Even though the motions of the hands 
be incoordinate and without force, though the infant may be unable to 
do anything for itself, even to grasp an object or to oppose the thumb 
to the fingers, there are many methods of overcoming such defects and 
developing the normal power and usefulness of the hands. Among these 
is the employment of the parallel swinging-ladders and rings. At first 
the child's hands are applied to the rounds and held there by the teacher 
during the execution of such movements as standing, sitting down, 
raising the arms high above the head, and bending forward and back- 
ward, swinging to and fro, and so on. 

As the pupil makes progress, the drill is carried on with great reg- 
ularity and precision, accompanied by spoken commands and often with 
music. In this way not only are the muscles strengthened and coordi- 
nated and the use of the hands and feet perfected, but a familiarity 
with certain words and ideas and their association is created. 

The use of blocks in building up various structures, with the subse- 
quent pleasure of tumbling them down again, is as useful to these defec- 
tives as to normal infants. 

Finger-exercises with the peg-board, or by means of picture-perforat- 
ing, as practised in the kindergarten, may come into play for the devel- 
opment of the finger movements of the hand. Some of the apparatus 
employed in educating the sense of touch are equally valuable for train- 
ing the accurate movements of the hands. 

Teaching- Habits of Cleanliness in Person and Dress. — Idiots 
of every degree are slovenly, awkward, negligent, unless taught and 
supervised, and the lower grades are incompetent to use spoon, knife, or 
fork, unable to care for themselves in any way, and continually drooling, 
sucking their fingers, holding the mouth open, and wetting and soiling 



904 MENTAL DISEASES. 

themselves. It is of paramount importance, then, in their education to 
make every effort to overcome these deficiencies. 

Such children as are unable or just learning to walk are placed by 
day in especially constructed chairs, and by night in especially prepared 
beds, for purposes of cleanliness, and must be watched and raised at 
certain hours by the nurses. It is surprising how many will, by assidu- 
ous attention, soon learn to give some signal to the care-takers of their 
needs, and in the end acquire control over themselves in this regard. 
They learn to expect the regular bath, and those who progress further 
become systematic in ablutions, cleansing the teeth, and all the little 
matters pertaining to the toilet. At the table they are taught first the 
use of the spoon, then of the fork, and lastly of the knife. They learn 
to dress themselves and to make themselves neat and tidy, and ulti- 
mately to brush and arrange their clothing, blacken their shoes, make 
their beds, etc. All of this instruction requires time and the utmost 
perseverance and patience on the part of the attendants. By it we 
also train the hands, the senses, and the intellect. 

To close the mouth and prevent drooling, faradic electrization of the 
orbicularis oris is employed, and the insertion of a flat piece of wood 
or a stick of licorice-root in the mouth is useful. The teeth need 
careful looking over by a dentist from time to time, and daily 
cleansing. Sucking of the fingers and biting of the nails can be 
overcome by application of aloes and other bitter or disagreeable 
substances. 

The Teaching- of Language. — In idiots we must begin our incul- 
cation of the uses of language according to the laws of its evolution in 
the normal child, first, however, correcting such defects in the ear, 
mouth, or vocal apparatus as are amenable to medical or surgical treat- 
ment. A child first develops its auditory word-center and then the 
motor speech-center. These two centers, with an association tract, are 
the primitive basis of language in the child. Often, in defective 
children, a course of gymnastic exercises of the lips, tongue, and jaw 
will be a necessary adjunct to the instruction, and in cases of deafness 
the lip-imitation method of education will require to be used. 

In developing the motor speech-center the child begins by repeating 
the simplest Unguals and labials, such as " dadda," " tatta," " mamma," 
" papa," and " babba," and these first consonants should be employed in 
the construction of the new words to be learned. 

Music is an excellent auxiliary in teaching the articulation and use 
of words, and Shuttleworth recommends Elliott's " National Nursery 
Rhymes," set to pleasing melodies, as particularly adapted for the pur- 
pose. The interest of the pupil is often best secured and sustained 
by the employment of objective illustrations. The naming of subjects 
of pictures, of persons and things about the room, of parts of the 
body, and the imitation of cries of animals, are means of arousing 
interest. 

After developing the word-hearing and the motor speech centers, 
the visual and writing centers will require education, and the methods 
in vogue are analogous to those of the kindergarten. Bourneville 



IDIOCY. 905 

recommends the use, first, of black letters twelve centimeters high ; then 
an alphabet with the consonants in black and the vowels in red, the 
letters six centimeters in height = then letters of ordinary size ; and, 
finally, the repetition, in chorus, of letters and words placed before a 
class. This collective exercise, in which imitation plays a great part, 
contributes markedly to the development of speech. Figures are 
employed in much the same manner, and counting is learned from 
some of the various apparatus already described, as well as from 
simpler and more interesting devices, such as the use of the fingers, 
shells, marbles, buttons, beads, and the abacus. The nursery game of 
keeping shop is especially useful for developing the ideas of number, 
weights, and values. 

Writing and drawing are taught by means of sand-boxes, blackboard 
exercises, and, finally, drawing-books. The knowledge of form is best 
inculcated by modeling in clay, and by reproductions in clay or wood 
of surface drawings. 

From these primary lessons it is but a step to 

Manual and Industrial Training-. — When the pupil has reached a 
certain stage of mental development, every effort is made to farther 
the training to such an extent as to subserve the demands of health and 
utility. Methods of manual and industrial education are best furthered 
in institutions in which every variety of occupation commensurate with 
the individual needs and tastes of the pupils can be satisfactorily carried 
out. In most existing institutions it is true that the ideal system of 
care and development of defectives has not yet been attained, but the 
tendencies of the present time are in the right direction. The insti- 
tutions of the future for all classes of dependents, for idiots, for the in- 
sane, and for the inmates of prisons and reformatories, will doubtless be 
modeled on the colony plan. They will be village settlements or com- 
munities wherein the chief industries will be such as relate to the 
housing, clothing, feeding, etc., of their inhabitants, thus bringing into 
existence all of the occupations which tend to utility and economical 
administration. The scheme is well exemplified and successfully dem- 
onstrated by the evolution of the Craig Colony for Epileptics at 
Sonyea, N. Y. Were I called upon to draw up an outline of a plan for 
a colony for idiots, it would be somewhat as follows : 

1. In the first place, there should be an abundance of land, at least 
an acre for each inhabitant. The site should be selected with due 
regard to fertility of soil ; for agriculture, stock-raising, and gardening 
should afford employment for the majority of the pupils. 

2. Convenience of access to managers and patients and their friends 
is a desideratum. 

3. In the construction and arrangement of buildings the country- 
village idea should never be lost sight of, and the farmstead group — 
the cottages, villas, schools, shops, and so on — should be simple, inde- 
pendent, homelike, and surrounded by their own little gardens, hedges, 
etc., in conformity with such design. 

4. So far as possible, each house should constitute a home circle, 
the number of members being limited to ten or fifteen. 



906 MENTAL DISEASES. 

5. An administration building, a small hospital for the sick, special 
villas for the infirm, bed-ridden, ineducable, and disturbed classes, a 
gymnasium, a library, a museum, and swimming- and rain-bath, are 
among the separate structures required in addition to those already 
mentioned. 

6. The educational features of the colony will be carried on in ordi- 
nary schools, Sloyd schools, trade schools, and so on, and everything 
that may contribute to the furtherance of mental development should 
be encouraged. Thus the field study of natural history is one of the 
most satisfactory means of arousing the intelligence, interest, and activity 
of the pupils. Trees, garden produce, and flowers should be labeled 
with their names, botanical and zoological gardens should be estab- 
lished, and the collection of rocks, leaves, plants, insects, birds, etc., 
made a part of the system. 

7. In developing the industries of the colony, such should first be 
instituted as will serve economical purposes. The aim should be to 
produce most of the foodstufls required, to carry on domestic work, to 
make and mend the wearing apparel, to accomplish ordinary repairs, to 
construct new buildings, and to fashion the furniture. 

8. The whole scheme requires to be under medical supervision, 
and the scientific aspects of the community thus created should be 
kept continually in mind. This necessitates the establishment of 
psychological and pathological laboratories after the most approved style. 

As an instance of what species of work may be done by defectives 
in institutions, Bourneville's statistics of occupations at Bicetre for 
1897 show that there were 187 children employed in the various shops 
and workrooms, among them being : 10 brushmakers, 24 carpenters, 9 
printers, 14 locksmiths, 51 tailors, 28 shoemakers, and 14 straw- and 
cane-workers. The hemiplegics work exclusively at sewing, and the 
blind with straw and cane. The colony plan, however, would insure a 
greater amount of healthier work out of doors than is possible at such 
a place as Bicetre, and would be more remunerative to the administration. 

Moral Training- and Discipline. — Much as the inculcation of 
moral ideas is needed for normal children, defectives require even 
more attention in this respect ; for in them the abrogation of higher in- 
telligence is associated naturally with feeble inhibitive power. Thus 
they easily give way to the lower instincts, and are prone to acquire 
vicious habits of conduct and speech. In some cases the moral obliquity 
is so great that it constitutes the so-called moral imbecility, and little can 
be accomplished for their improvement. But the majority of defectives 
are susceptible to the influences of a good environment and moral disci- 
pline. Imitation of the teacher and of playmates and schoolmates counts 
for much with them. The judicious instructor and care-taker can, by 
firm and kindly guidance, accomplish great good in this respect, and it 
should always be kindly guidance, never coercion. There is, however, 
merit in the employment of a system of rewards and punishments 
adapted to the idiosyncrasies of the different pupils. A few words of 
encouragement or praise, or trifling compensations in the way of extra 
allowances of food, delicacies, recreations, or small wages, appeal dis- 



IDIOCY. 907 

tinctly to some ; while words of disapproval, the curtailing of things 
pleasant to the palate, the deprivation of some anticipated pleasure, and 
so on, have especial influence with others. It is a good plan to dis- 
tinguish the pupils for meritorious conduct and industrial accomplish- 
ments by distinctive dress, thus appealing to their ambitions. It is well 
to establish three or four grades to be thus distinctively recognized, for 
nothing is more human than the instinct to appear well to others, to be 
among the best-dressed. The instinctive desire of the savage for orna- 
ment is no stronger than that of the most civilized being for good 
clothes. The mentally feeble are no strangers to this feeling, and their 
good conduct can be enhanced and maintained by promotion to a better 
clothed division, and their shortcomings well punished by reduction to a 
lower rank. Corporal punishment is both necessary and useful in ex- 
treme cases with vicious tendencies, but should be a last resort even here. 

By the means just described, and by other devices that will sug- 
gest themselves to the wise and tactful person whom we suppose to be 
intrusted with their care, these unfortunates may be taught obedience, 
perseverance, responsibility, and regard for the rights of others, and be im- 
bued with some knowledge of the great laws of justice, beauty, goodness, 
and religion which rule the ideal world of humankind. 

Physical Culture. — The tendency to incorrectness of gesture and 
bearing, the great lack of strength and grace, among idiots, must be 
overcome by systematic education of the muscles. There should be 
courses of gymnastic exercises and drills, with song and instrumental 
accompaniments. The drills may be made with wands, light dumb- 
bells, etc. Military drill is excellent for both girls and boys. Dancing 
is beneficial to both mind and body. Bourneville has introduced 
fencing at Bicetre, but does not speak of it with enthusiasm. 

The Medical and Surgical Treatment of Idiocy. — At one time 
craniectomy had considerable vogue as a measure in the treatment 
of microcephalic idiocy, under the idea that the brain was hindered 
in development by premature synostoses of the skull bones. Inves- 
tigation showed, however, that the sutures are normal in micro- 
cephalic skulls and not synostosed, and surgical experience finally dem- 
onstrated that nothing was accomplished by the operation. It has been 
hoped to do some good by surgical intervention in chronic hydrocephalus, 
but thus far the results have not justified any procedure of this kind. 
In idiocy due to trauma of the head trephining for decompression 
purposes (the ventil operation of Kocher or decompression operation of 
Cashing) should be carried out, even in cases of long standing. 

Myxedematous idiocy should, of course, be treated by the adminis- 
tration of thyroid extract over long periods of time, and if undertaken 
early enough, oifers hope of a permanent cure. 

Hydrotherapy. — The rain-bath is nowadays considered a necessary 
adjunct to all public institutions, because of expedition in its use and 
perfect cleanliness. Such baths should be the daily morning rule of 
defectives. The skin is kept in a hygienic state, the circulation is 
stimulated, and general nutrition is improved by the morning bath. In 



908 MENTAL DISEASES. 

lethargic or apathetic states the cold spinal douche is beneficial, while 
in very restless patients the prolonged warm bath and wet-packs at 
night often materially aid in overcoming the condition. 

Clothing-. — One of the noteworthy stigmata of degeneration common 
to all classes of idiocy is a diminished resistance to external influences 
and diseases. They catch cold easily. Tuberculosis and other lung dis- 
orders account for nearly seventy-five per cent, of the mortality among 
them. Diarrheas are common. Hence it is important that, among 
other things, considerable attention should be given to clothing. Woolen 
undergarments of warm and light texture should be the rule. The 
outer clothing should be light, durable, neat, of prevailing cuts and 
styles, and none of the clothing should in any way impede or restrict 
the free motions of the limbs and trunk. 

Food. — The dietary for this class of defectives should, in my 
opinion, closely approximate that of epileptics — i. e., it should be chiefly 
vegetable, with the free use of milk and eggs, and meat but once daily. 
Simplicity of food and simple cooking are essential. The dietary need 
not be so elaborate as, for instance, in hospitals or asylums, where acute 
disorders are commonly treated, and where the percentage of cure is 
expected to be large. Idiots are apt to overeat, and hence the chief 
requisite is to regulate the per capita allowance to just the amount 
necessary to maintain a robust state of physical health. Overeating is 
probably responsible for much of the diarrhea commonly observed 
among these cases. 

General Bodily Health. — Very common is a condition of general 
debility, which must be met by appropriate tonics, nutritive foods, 
special baths, massage, and regular exercise. The great mortality from 
tuberculosis should lead the physician to a regular examination of the 
viscera for symptoms of that disorder. When discovered, the usual 
precautions should be taken to isolate the patient and to build up the 
constitution in every way. Parasitic and nervous skin diseases will 
often need attention. The prevailing mucous diarrheas are treated by 
the usual remedies and by careful regulation of the kind and amount of 
food. Owing to feebleness of constitution and diminished resistance to 
diseases, especial danger attaches to acute infectious fevers in idiots. 

Masturbation. — The prevalence of this pernicious habit among all 
classes of idiots is only too pronounced. In the lowest grades it is un- 
common, but among the imbeciles and feeble-minded it is one of the 
most intractable of conditions. There are few agents and devices 
which have not been tried, and usually vainly, to prevent the practice. 
It is only rarely that vesication of the genitals, punishment, mechanical 
restraint of the limbs, and sedative drugs have any effect in the treat- 
ment of defectives. Indeed, they might usually as well be left untried. 
There have been very few experiments of the method of cure by cas- 
tration, for, naturally, professional opinion is too conservative to under- 
take, without long and careful deliberation, so radical a remedy. I know 
of but one institution where castration has been apparently adopted as 
a part of the regular system of care and treatment. The superintendent 



IDIOCY. 909 

of the Winfield, Kansas, Asylum for Idiots has had between twenty 
and thirty boys who were inveterate masturbators subjected to castra- 
tion, with excellent results. Not only were their vicious habits put an 
end to, but there was marked physical improvement in all, and great 
mental improvement in most, of them. There would seem to be no 
reasonable objection to operative procedure in such cases, though, per- 
haps, it is hardly necessary to go so far as castration. Ligature of the 
vas deferens, or possibly section of some branch of the pudic nerve, 
might serve as well. At any rate, some method of this kind is well 
worthy of consideration, though the ultimate decision of the profession 
as to its utility and propriety has yet to be learned. 



INDEX. 



Abdominal reflex, 35 
Abscess of brain, 243 
diagnosis of, 246 
encysted, 244 
etiology of, 243 
headache in, 246 
invasion stage of, 245 
latent period of, 245 
multiple, 244 
paralytic stage of, 245 
pathological anatomy of, 243 
prognosis of, 247 
remission stage of, 245 
symptoms of, 245 
treatment of, 247 
Accessory, spinal, 151. See also Spinal 

accessory nerve. 
Accommodation, errors of, importance 
of, 63 
in multiple neuritis, 326 
Acetonuria in insanity, 755 
Achilles-tendon reflex, 37 
Achromatopsia, 65 
Aconite in cerebral hemorrhage, 222 

in hematomyelia, 364 
Aconitia of Duquesnel in neuralgia, 665 
Acrocephalus, 695 
Acromegalia, 503 
course of, 509 
diagnosis of, 509 
differential diagnosis of, 509 
etiology of, 504 
forms of, 509 
morbid anatomy of, 505 
prognosis of, 509 
symptoms of, 506 
treatment of, 509 
Acroparasthesia, 543, 673 
Actinomycosis of brain, 262 
Actions, disorders of, 749 

induced by defects of memory, 749 
by disorders of emotions, 749 

of idea-association, 750 
by sensory disorders, 749 
Active electrode, 42 
Acupuncture in sciatic neuritis, 315 
Acute anterior poliomyelitis, 388. See 
also Poliomyelitis. 
ascending paralysis, 376. See also 
Landry's paralysis. 
Addison's keloid, 534 
Adenolipomatosis, 551 
Adiadococinesia, 192 
Adiposis dolorosa, 511 



Adiposis dolorosa, diagnosis of, 513 
etiology of, 511 
pathology of, 513 
symptoms of, 511 
treatment of, 513 
Adiposity, 510 

Adonis vernalis in epilepsy, 857 
Adventitious neuritis, 290 
Affective agitation, 758 
Age in etiology of insanity, 689 
Ageusia, 67 

Agitated depression, 782 
Agoraphobia, 602, 747 
Agraphia with motor aphasia, 181 
Alcohol in cerebral hemorrhage, 222 
palsies of children, 257 

in etiology of insanity, 714 

in trifacial neuralgia, 666 
Alcoholic hallucinosis, 715 

neuritis, 329 

prognosis of, 334 

paranoia, 715 

psychoses, 813 
Alcoholism, chronic, 715 
Alexia, 104 

Alienation mentale, 679 
Alimentary canal, examination of, 24 
Allocheiria, 54 
Alpine scurvy, 476 
Amaurotic family idiocy, 255 
Amaxophobia, 602 
Amenorrhea in insanity, 755 
American disease, 592 
Amimia, 69, 179 
Amnesia, 742 

retrograde, 742 

verbalis, 69 
Amputation neuroma, 294 
Amusia, 179 

Amyelinic neuromata, 294 
Amyl nitrite in angina pectoris, 150 

in Raynaud's disease, 542 
Amylene hydrate in mental disease, 

778 
Amyotonia congenita, 424 
Amyotrophic lateral sclerosis, 406. See 

also Progressive muscular atrophy, 

spinal. 
Anal reflex, 38 

sphincteric, 38 
Analgesia, 54 

in myelitis, 368 

in syringomyelia, 401 

in tabes dorsalis, 439 

911 



912 



INDEX. 



Anemia, cerebral, 201 

combined cord-lesions in, 466 
Anesthesia, 54 

from lesion of anterior crural nerve, 
308 
of circumflex nerve, 299 
of external plantar nerve, 310 
from lesions of spinal cord, 349 
from paralysis of sciatic nerve, 309 
hysterical, 57, 613 
distribution of, 616 
peculiarities of, 617 
in mental disease, 734 
in syringomyelia, 401 
of larynx, 154 

relation of, to lesions of cord, 55 
to lesions of nerve-trunks, 55 
Aneurysms of brain, 262 
Anger, 739 
Angina cruris, 543 
pectoris, 149 
hysterical, 632 
Angioma of brain, 262 
Angioneurotic edema, 545 
diagnosis of, 546 
etiology of, 545 
prognosis of, 547 
symptoms of, 546 
treatment of, 547 
Angiosclerotic paroxysmal myasthenia 

543 
Anhedonia, 735 
Ankle-clonus, 37 

spurious, 38 
Anodal closing contraction, 44 

opening contraction, 44 
Anodynes in neuritis, 293 

in neuromata, 296 
Anomalies, dental, in insanity, 705 
of appetite in insanity, 713 
of body in insanity, 711 
of cranium in insanity, 698 
of ear in insanity, 706 
of eyes in insanity, 706 
of genital organs in insanity, 709 
of genito-urinary function in insanity, 

713 
of instinct in insanity, 713 
of limbs in insanity, 711 
of lips in insanity, 705 
of motor function in insanity, 712 
of nose in insanity, 706 
of sensory function in insanity, 712 
of skin in insanity, 712 
of speech in insanity, 713 
of tongue in insanity, 705 
Anorexia, hysterical, 633 
Anterior horn of cord, effect of lesions of, 
244 
median artery of cord, 342 
roots of cord, effect of lesions of, 352 
spinal artery, 342 
Antipyretics in tubercular leptomenin- 
gitis, 96 
Antipyrin in brain tumor, 272 
in chorea, 569 
in epilepsy, 652 



Antiseptics in sinus thrombosis, 240 
Antistreptococcus serum in chorea, 569 
Anxiety, 738 
Apathy, 739 

from tumors in corpus callosum, 188 
Ape hand, 302, 411 
Aphasia, 68, 176 
auditory, 180 
combined, 184 
complete, 181 
conduction, 183 

examination and testing, of 69 r 
graphic motor, 183 
in cerebral hemorrhage, 214 
in tumor of brain, 266 
motor, 180 

handwriting in, 181 
varieties of, 176 
visual, 182 
Aphasics, reeducation of, 184 
Aphemia, 180 
Aphonia in hysteria, 68 
Aphthongia, 155 
Apituitarism, 502 
Apomorphin in chorea, 569 
Apoplectic state, 212 

"stroke," 212 
Apoplexy, ingravescent, 219 
Apperceptive dementia, 806 
Appetite, anomalies of, 713 
Apraxia, 70, 171, 179, 182- 

in tumor of brain, 266 
Arachnopia, 72 
Arc de cercle, 625 
Argyll-Robertson pupil, 34 

in insanity, 753 
Arm, nerves of, combined palsies of, 304 
Arsenic in beer, multiple neuritis from, 
317, 326 
in chorea, 569 
in multiple neuritis, 336 
in neurasthenia, 601 
Arterial brain diseases, 199 
Arteries, acute degeneration of, 209 
of brain, 199 
of spinal cord, 342 
Arteriosclerosis, cerebral, 205 
symptoms of, 206, 207 
treatment of, 207 
Arteritis, cerebral, 204 
syphilitic cerebral, 489 
of brain, 208 
symptoms of, 492 
Artery, anterior median, of cord, 342 

spinal, 342 
Arthritic muscular atrophy, 40, 425 
diagnosis of, 425 
etiology of, 425 
morbid anatomy of, 426 
pathology of, 426 
prognosis of, 426 
symptoms of, 425 
treatment of, 427 
Arthritis, acute, in cerebral hemorrhage, 
215 
diplococcus of Weichselbaum in, 79 
relation of, to chorea, 560 



INDEX. 



913 



Arthropathies in syringomyelia, 403 
Arthropathy, dystrophic, 40 

tabetic, 450 
Aschistodactyly, 711 
Aspirin in tabes dorsalis, 462 
Associated movements, 32 

in infantile cerebral palsies, 252 
Association disease, 648 
Astasia abasia, 650 
Astereognosis, 51 
Asthenic bulbar paralysis, 164 
Asthma, bronchial, 145 
symptoms of, 146 
treatment of, 146 
spasmodic, 145. See also Asthma, 
bronchial. 
Asturian leprosy, 476 
Asylums for insane, 767 
Asymmetrical palate, 701, 704 
Asymmetry, facial, 699 
of skull, 704 

physiological, 704 
Atavism in mental and nervous diseases, 

18 
Ataxia, detection of, 29, 30 

family, 468. See also Family ataxia. 
Friedreich's, 469. See also Family 

ataxia. 
hereditary cerebellar, 469 
in tabes dorsalis, 435 
intrapsychic, 804 
locomotor, progressive, 428. See also 

Tabes dorsalis. 
progressive spastic, 463 
static, 30 
Ataxic gait, 435 
handwriting, 30 
paraplegia, 463 
syphilitic, 496 
Atheroma of cerebral vessels, 204 
Atheromatous arteries in etiology of 

insanity, 718 
Athetoid movements in infantile cerebral 

palsies, 251 
Athetosis, 32 

in infantile cerebral palsies, 251 
treatment of, 257 
Athyroidism, 513 

Atonic pseudoparalysis, congenital, 424 
Atoxyl in sleeping sickness, 673 
Atrophia muscularis progressiva spinalis, 

405 
Atrophy, arthritic, muscular, 40, 425. 
See also Arthritic muscular atrophy. 
from lesions of spinal cord, 350 
in facial paralysis, 128 
in multiple neuritis, 322 
in myelitis, 368 
in syringomyelia, 402 
of optic nerve. 107 

progressive muscular, 405. See also 
Progressive muscular atrophy. 
Atropin in etiology of insanity, 716 

in myoclonia, 573 
Attention, disorders of, 742 
Attitude, importance of, 28 

in idiopathic muscular atrophy, 419 

58 



Attitude in paraplegia, 375 

in sciatic neuritis, 418 
Auditory aphasia, 180 

hyperesthesia, 65, 133, 134 
nerve, electrical testing of, 49 
irritation of, 133 
paralysis of, 134 
symptoms in cerebellar disease, 193 
Aurse, epileptic, 643 
Aural vertigo, 136 
diagnosis of, 137 
treatment of, 139 
Auric ulobregmatic radii, 696, 699 
Autohypnosis, 672 
Auto-intoxication in etiology of insanity, 

714 
Automatic obedience in dementia prsecox, 

805 
Aztec ear, 708 

Babinski's toe-sign, 37 

Bacillus coli in leptomeningitis, 79 

tubercle in leptomeningitis, 79 
in tubercular meningitis, 92 
Barany's labyrinthine test, 138 
Basal ganglia, functions and lesions of, 

189 
Basedow's disease, 523. See also Exoph- 
thalmic goiter. 
Basilar meningitis, 91. See also Lepto- 
meningitis, tubercular. 
Basion, 697 

Batteries for electrical testing, 41 
Beard's disease, 592 
Bedsore in cerebral hemorrhage, 214 
Beer, arsenic in, multiple neuritis from, 

317, 326 
Belladonna in epilepsy, 653 

in exophthalmic goiter, 532 

in nocturnal enuresis, 672 
Bell's palsy, 125 
Benedict-Weber syndrome, 190 
Benedikt's calipers, 697, 698 
Beri-beri, 317, 331 
Beri-berie residual paralysis, 332 
Betanaphtol, 652 

in auto-intoxication, 776 

in epilepsy, 858 

in myelitis, 372 
Bichlorid of mercury in anterior myelitis, 
396 
in Landry's paralysis, 380 
Bier's treatment in writer's cramp, 591 
Binauricular arc, 696, 699 

diameter, 696, 699 
Blainville ear, 707 
Blepharospasm as a symptom, 62 
Blindness, functional, 108 

toxic, 108 
Body, anomalies of, 713 
Bones, testing sensibility of, 54 
Brachial plexus, lesions of, 305 

neuritis of, 306. See also Neuritis. 
Brachy cephalic head, 694 
Bradycardia, 148 
Brain, abscess of, 243. See also Abscess 

of brain, 



914 



INDEX. 



Brain, aneurysms of, 262 
arterial supply of, 199 
carcinoma of, 260 
cysts of, 261 
disease, pain in, 62 
glioma of, 259 
inflammation of, 240 
lesions of, destructive, 194 
general considerations of, 194 
headache in, 196 
irritative, 194 
vertigo in, 196 
sarcoma of, 259 
softening of, 224 
syphilis of, 489. See also Syphilis, 

cerebral. 
tubercle of, 258 

tumors of, 258. See also Tumors of 
brain. 
syphilitic, 261 
Brandy in mania, 754 
Break of current, 42 
Bregmatolambdoid arc, 796 
Bright's disease as predisposing to ner- 
vous disease, 19 
Brodie's joints, 619 
Bromid in cerebral softening, 232 
in family periodic paralysis, 584 
of potassium in family periodic paral- 
ysis, 584 
in tubercular leptomeningitis of 
children, 96 
Bromids in brain tumor, 272 
in epilepsy, 652 

of infantile cerebral palsy, 257 
in exophthalmic goiter, 532 
in mental disease, 777 
in multiple neuritis, 337 
in myoclonus epilepsy, 649 
in paralytic dementia, 826 
in senile dementia, 813 
in tetanus, 555 
Bronchial asthma, 145. See also Asthma. 
Brown-Sequard paralysis, cord-lesion in, 

56, 57 
Bruit in intracranial aneurysms, 197 
Bulbar paralysis, acute, 164 
asthenic, 165 

progressive, 159. See also Polio- 
encephalitis inferior chronica. 
Bulbocavernous reflex, 447 
Bulimia, 735 



Cachexia, combined cord-lesions in, 466 

strumipriva, 514 
Caffein in brain-tumor, 272 

in family periodic paralysis, 584 
in migraine, 657 
Cagot ear, 709 
Caisson disease, 380 
etiology of, 380 
morbid anatomy of, 381 
prophylaxis of, 382 
symptoms of, 381 
treatment of, 382 
Calabar bean in tetanus, 555 



Calipers, 797, 798 
Calomel in hydrocephalus, 276 
in leptomeningitis, 87 
in tubercular leptomeningitis, 96 
Camphor in bronchial asthma, 147 
Cannabis indica in etiology of insanity, 
716 
in migraine, 657 
in Parkinson's disease, 580 
in torticollis, 152 
Carbolic acid in tetanus, 555 
Carcinoma in etiology of insanity, 718 

of brain, 260 
Cardiac branches of vagus, diseases of, 
147 
palpitation, 150 
Cardiopathy, relation of, to chorea, 560 
Cardiothyroid exophthalmos, 523 
Case-book, value of, 70 
Catatonic form of dementia prsecox, 808 
Cathodal closing contraction, 43 
tetanus, 44 
opening contraction, 44 
Cauda equina, lesions of, 360 
Center for elbow movements, 171 
for face movements, 171 
for finger movements, 171 
for hearing, 173 
for lower extremities, 171 

face movements, 171 
for platysma, 171 
for shoulder movements, 171 
for smell, 173 
for speech, 172, 176 
for taste, 173 

for tongue movements, 169 
for trunkal movements, 171 
for vision, 172 
for wrist movements, 171 
Centers, cortical, 169 

relation of body to, 172 
for word memories, 176 
motor, of cerebral cortex, 169 
Central canal of cord, effect of lesions of, 
352 
myelitis, 366 
scotoma, 104 
Cephalalgia, hysterical, 633 
Cephalic index, 794 

tetanus, 554 
Cerebellar hemorrhage, 220 
Cerebellopontine angle, tumors in, symp- 
toms presented by, 193 
Cerebellospasmodic gait, 482 
Cerebellum, function of, 191 
lesions of, headache in, 193 
symptoms of, 191 
vertigo in, 192 
Cerebral anemia, 201 
diagnosis of, 202 
etiology of, 201 
symptoms of, 201 
treatment of, 202 
arteriosclerosis, 205 
arteritis, 204 

syphilitic, 70, 207 
cortex, cells of, 168 



INDEX. 



915 



Cerebral cortex, latent lesions of, 173 
lesions of, effects of, on sensation, 57 
localization in, 167. See also Local- 
ization, cerebral. 
motor centers of, 169 
unknown functions of, 173 
hemorrhage, 209. See also Hemor- 
rhage. 
hyperemia, 202 
diagnosis of, 203 
etiology of, 202 
symptoms of, 203 
lesions in tabes dorsalis, 434 
meninges, anatomical considerations, 
12 
diseases of, 72 
meningitis, syphilitic, 489 
palsies of children, 248 

causes attending birth, 249 
classification of, 250 
diagnosis of, 256 
diplegic cases, 253 
epileptic attacks in, 256 
etiology of, 248 
hemiplegic cases, 250 
morbid anatomy of, 250 
postnatal causes of, 249 
prenatal causes of, 248 
prognosis of, 256 
symptoms of, 250 
treatment of, 257 
periarteritis, 204 
sinuses, 233 
softening, 224 

abrupt onset in, 227 
course of, 229 
diagnosis of, 229 
differential diagnosis of, 230 
etiology of, 226 
location of, 226 
paralytic state in. 228 
pathological anatomy of, 225 
prognosis of, 231 
progressive onset in, 228 
red, 225 

sensory disturbances in, 229 
symptoms of, 227 
treatment of, 232 
white, 225 
yellow, 225 
syphilis, 489. See also Syphilis, 

cerebral. 
veins, 233 

white matter, function of, in localiza- 
tion, 187 
Cerebritis, 240 

acute, localized, 240, 242 
etiology of, 240 
pathological anatomy of, 241 
symptoms of, 241 
treatment of, 242 
chronic, 243 

from cerebral hemorrhage, 214 
syphilitic, 489 
Cerebroma, 261 

Cerebrospinal meningitis, 78. See also 
Leptomeningitis. 



Charcot-Marie disease, 423 
Charcot's disease, 406, 413 

joints, 40, 451 
Chemocephalus, 795 
Chiasm, optic lesion of, 101, 105 
Children, cerebral palsies of, 248. See 

also Cerebral palsies of children. 
Chirospasm, 585 

Chloral hydrate in mental disease, 778 
in chorea, 568 
in insomnia, 669 
in multiple neuritis, 337 
in paralytic dementia, 826 
in status epilepticus, 858 
in tetanus, 555 
Chlorid of iron in anterior poliomyelitis, 
396 
tincture of, in Landry's paralysis, 380 
Chloroform in angina pectoris, 150 

in bronchial asthma, 147 

in tetanus, 555 
Cholesteatomata of brain, 262 
Chorea, 558 

adult hereditary, 570 

cardiac disorders in, 565 

chronic, 570 

complications of, 560 

corpuscles, 561 

course of, 566 

diagnosis of, 568 

electric, 568, 573 

etiology of, 558 

family, 570 

fibrillary, 572 

forms of, 567 

general state in, 566 

gravidarum, 567 

gravis, 567 

handwriting in, 564 

Huntington's, 570 

limp, 567 

mental symptoms of, 565 

minor, 558 

morbid anatomy of, 561 

motor symptoms of, 563 

of pregnancy, 567 

of Sydenham, 558 

of the aged, 570 

paralytic, 567 

pathogenesis of, 560 

prognosis of, 568 

relations of rheumatism to, 560 

senile, 572 

symptoms of, 562 

treatment of, 568 
Choreic status, 567 
Choreoid movements in infantile cerebral 

palsies, 251 
Choroiditis in leptomeningitis, 83 
Chronic delusional insanity, 827. See 

also Paranoia. 
Chvostek's sign, 538 
Ciliary reflex, 33 
Circular insanity, 794 
course of, 798 
etiology of, 795 
maniacal period of, 796 



916 



INDEX. 



Circular insanity, melancholy period of. 
795 
prognosis of, 784 
symptomatology of, 795 
treatment of, 799 
varieties of, 798 
Circulatory apparatus, examination of, 

25 
Circumflex nerve, lesions of, 299 
Claudication intermittente, 543 
Claustrophobia, 602, 747 
Cleft-palate, 702 
Clonic convulsions, 32 

spasm, 31 
Clonus, ankle-, 37 
foot-, 37 
rectus-, 37 
wrist-, 35 
Cqcain in etiology of insanity, 716 
in multiple neuritis, 336 
in myoclonia, 573 
in neuralgia, 629 
in sciatic neuritis, 316 
ointment in herpes zoster, 339 
Codein in epilepsy, 857 
in mental disease, 777 
Colloid of silver, Crede's, for leptomenin- 
gitis, 88 
Color-blindness, 65 
Coma, placid, from tumors in corpus cal- 

losum, 188 
Combined aphasias, 184 

cord-lesions in anemias and cachexias, 

466 
palsies of nerves of arm, 304 
sclerosis of the spinal cord, 463 
course of, 465 
diagnosis of, 465 
etiology of, 463 
morbid anatomy of, 463 
prognosis of, 466 
symptoms of, 464 
treatment of, 466 
tabes, 463 
Commotion insanity, 720 
Concussion of spine, 658 
Conduction of aphasias, 183 
Congenital atonic pseudoparalysis, 424 
myxedema, 516 
paramyotonia, 581 
Conjunctivitis in facial paralysis, 128 
Consanguinity of parents as a predispos- 
ing cause of nervous disease, 18 
Constant current, test of, in health, 42 
Continuous epilepsy, 649 
Contraction, anodal closing, 44 
opening, 44 
cathodal closing, 43 

opening, 44 
front-tap, 37 
paradoxical, 37 
Contracture, 31 

Contractures from cord-lesions, 347 
in infantile cerebral palsies, 251, 252 
in multiple neuritis, 323 
of hysteria, 628 
Convulsions, 32 



Convulsions, clonic, 32 

general, 32 

in cerebral palsies of children, 251 

in leptomeningitis, 82 

in tubercular leptomeningitis, 94 

in tumor of brain, 264 

Jacksonian, 32 

local, 32 

tonic, 32 
Coprolalia, 606, 748, 808 
Cord- lesions, combined, in anemias and 
cachexias, 466 

cross, table of symptoms in, 353-359 

horizontal localization of, 351 

indiscriminate, 362 

motor symptoms of, 347 

paralysis from, 347 

reflexes in, 349 

sensory symptoms of, 349 

trophic conditions in, 350 

vasomotor disturbance in, 350 

visceral symptoms of, 350 
Cord-substance, traumatic lesions of, 362 
Corona radiata, function of, 186 
Corpora quadrigemina, function of, 189 
lesions of, 105 
symptoms of, 189 

striata, function of, 189 
Corpus callosum, function of, 188 
Cortex, cerebral. See Cerebral cortex. 
Cortical localization, motor, 169 
sensory, 172 

paralysis in insanity, 752 
Coughs, nervous, 145 
Counterirritation in combined sclerosis 
of cord, 466 

in Landry's paralysis, 380 

in neuritis, 293 

in sciatic neuritis, 315 

in spinal leptomeningitis, 283 

in syringomyelia, 405 

in tabes dorsalis, 460 
Coxalgia, hysterical, 630 
Cramp, 31 

writers', 585 
Crania progenaea, 697 
Cranial anomalies, 693 

nerves, affections of, in leptomeningitis, 
82 
lesions of, in tabes dorsalis, 434 
multiple paralyses of, 156 
syphilitic lesions of, 486 
Craniectomy in microcephalic idiocy, 907 
Craniocerebral topography, 173 
Craniometrical measurements, 696 

table of, 699 
Cranium, anomalies of, 693 

deformities of, 693 

measurement of, 696 

phvsiological asymmetry of, 694 
Cranks, 827 

Crede's colloid of silver ointment for lep- 
tomeningitis, 88 
Cremasteric reflex, 38 
Cretinism, 516 

sporadic, 516 
Crises, gastric, 445 



INDEX. 



917 



Crises, laryngeal, 448 

nephritic, 447 

pharyngeal, 448 

tabetic, 445 

visceral, 445 
Cross-lesions of cord, table of symptoms 

in, 353-359 
Crura cerebri, function of, 190 

results of lesions of, 190 
Crural nerve, anterior, lesions of, 308 
Curare in tetanus, 555 
Current, break of, 42 

make of, 42 
Cushing's decompression operation in 

idiocy, 907 
Cutaneous areas, relation of, to spinal- 
cord segments, 56, 59 

distribution of nerves, 52, 53 

sensibility, electrical testing of, 49 
Cycloplegia, 63 
Cysts of brain, 261 

subdural, of spinal cord, 384 



Daltonism, 65 

Dammerzustande, 851 

Darwin ear, 708 

Deafness, diagnosis of cause of, 135 

nervous, 134 

treatment of, 135 

word-, 134 
Debilitating diseases as predisposing to 

nervous disease, 18 
Decompression operation for idiocy, 907 
Decubitus from trophic disturbance, 40 
Deformity from cerebral palsies of chil- 
dren, 251 
Degeneracy, stigmata of, 21 
Degeneration, progressive lenticular, 189 

reaction of, 46 

secondary, of divided nerve, 287 

stigmata of, 304 
Delire de negation generalize, 746 
Delirium inanition, 718 

in anterior poliomyelitis, 392 

in leptomeningitis, 81 

in multiple neuritis, 327 

tremens, 715 
Delusion of grandeur, 746 

of negation, 746 

of persecution, 745 
Delusions, 744 

effect of, on actions, 751 

in paralytic dementia, 820 

systematization of, 747 
Dementia, 810 

apperceptive, 806 

definition of, 810 

epileptic, 853 

paralytic, 810, 813 
definition of, 813 
diagnosis of, 822 
duration and prognosis of, 822 
etiology of, 814 
pathological anatomy of, 825 
symptomatology of, 816 
treatment of, 826 



Dementia praecox, catatonic form of, 802, . 
810 
classification of, 802 
diagnosis of, 809 
etiology of, 802 
hebephrenic form of, 807 
paranoid type of, 809 
prognosis of, 809 
simplex, 807 
symptoms of, 803 
treatment of, 810 
secondary, 810 
sejunctiva, 806 
senile, 810, 811 

course and prognosis of, 812 
diagnosis of, 812 
etiology of, 811 
pathological anatomy of, 812 
symptomatology of, 811 
treatment of, 813 
senilis, praecox, 811 
Depression, 737 
agitated, 782 
Dercum's disease, 511 
Dermatagra, 476 
Dermographism in hysteria, 635 
Destructive brain-lesions, 194 
Destructiveness in insane, management 

of, 781 
Diabetes a predisposing cause to nervous 

disease, 19 
Diagnosis in neurology, importance and 

difficulty of, 17 
Diet in insanity, 773 

in leptomeningitis, 88 
Diffused symptoms, 195 
Digitalis in epilepsy, 653 

in exophthalmic goiter, 532 
Digiti mortui, 541 
Diphtheric paralysis, 330 
Diplegia, 29 

in infantile cerebral palsies, 253 
Diplococcus intercellularis meningitidis 
in leptomeningitis, 79 
of Weichselbaum in leptomeningitis, 79 
variety of meningitis, 90 
course of, 90 
diagnosis of, 90 
etiology of, 90 
prognosis of, 90 
symptoms of, 90 
treatment of, 90 
Diplopia, 63 

in ocular paralysis, 111 
monocular, 63 
test, 112 
Disease, electrical tests in, 45 
Diseases in etiology of insanity, 717 
Disorders of actions, 748 

of idea-associations, 739 
Disorientation, 741 
Disseminated myelitis, 366 

sclerosis, 479. See also Multiple 
cerebrospinal sclerosis. 
Distractibility in mania, 785 
Disuse, trophic disturbance from, 40 
Diver's palsy or paralysis, 380 



918 



INDEX. 



Diver's palsy, etiology of, 380 
morbid anatomy of, 381 
symptoms of, 381 
treatment of, 382 
Division of nerves, 287 
Dolichocephalic heads, 794 
Dome-shaped palate, 701, 703 
Dreams, 23, 670, 765 
Freud's views, 766 
Drop-foot in multiple neuritis, 320, 321 
Drop-wrist in multiple neuritis, 322 

in musculospiral disease, 301 
Drunkenness, pathological, 715 
Dubini's disease, 573 
Duboisin in epilepsy, 858 
in mania, 789 
in mental disease, 777 
Duchenne- Aran's disease, 406, 413 
Dura mater, 72 

hematoma of, 74 

inflammation of, 74. See also 
Pachymeningitis. 
Dynamometer, hand-, of Mathieu, 28 
Dysacousma, 65 
Dysesthesia, 55 
Dyspepsia, nervous, 151 
Dystrophic arthropathy, 40 
Dystrophy, genital, 510 



Ear, anomalies of, 717 
Aztec, 708 
Blainville, 708 
Cagot, 709 
Darwin, 708 
insane, 771 
Morel, 707, 708 
Stahl, No. 1, 707, 708 

No. 2, 708 
Wildermuth, 702, 710 
Echolalia, 68, 178, 761, 808 
Echopraxis, 761, 808 
Ecstasy, hysterical, 617 
Ectrodactyly, 711 
Ectromelus, 711 

Edema, acute circumscribed, 544 
angioneurotic, 545 
chronic hereditary, 552 
Education of idiots, 893 
Eighth cranial nerve, anatomical con- 
siderations of, 154 
diseases of, 154 
nerve, auditory branch of. See Audi- 
tory nerve. 
vestibular branch of. See Vestibu- 
lar nerve. 
Elbow, center for movements of, 171 
Elbow-jerk, 34 
Electrical chorea, 568, 573 
conditions, 41 

examination in polioencephalitis in- 
ferior chronica, 162 
testing, arrangement of electrodes in, 
42 
batteries for, 41 
for motor areas of brain, 49 
in disease, 45 



Electrical testing of cutaneous sensibilitv, 
49 
of hearing, 49 
of taste, 49 
of vision, 49 

tests in health, 42 
Electricity in anterior poliomyelitis, 397 

in exophthalmic goiter, 532 

in facial paralysis, 131 

in family ataxia, 475 

in infantile cerebral palsies, 257 

in intermittent limping, 544 

in Landry's paralysis, 380 

in laryngeal paralysis, 144 

in multiple neuritis, 337 

in myelitis, 372 

in neurasthenia, 601 

in neuritis, 293 

of brachial plexus, 308 

in psychasthenia, 605 

in Raynaud's disease, 200 

in sciatic neuritis, 215 

in spinal progressive muscular atrophy, 
414 
Electrode, active, 42 

indifferent, 42 
Electrodes, arrangement of, in electrical 

testing, 42 
Electrotherapy in insanity, 776 
Embolism, cerebral, 112 

disorders of, actions induced by, 749 
Emotional indifference in dementia prse- 

cox, 804, 805 
Emotions, galvanometer test for, 764 

in dementia prsecox, 804 

word-association test for, 763 
Empirical greatest height of head, 696 
Emprosthotonos in cerebellar disease, 192 
Encephalitis, acute hemorrhagic, 242 
diagnosis of, 243 
etiology of, 242 
morbid anatomy of, 242 
symptoms of, 243 
treatment of, 243 

chronic, 243 

in cerebral softening, 225 
Encephalomalacia. See Cerebral soften- 
ing. 
Endarteritis deformans of cerebral ves- 
sels, 204 
Enfants ariearre, 519 
Enuresis, nocturnal, 671 
Epicritic sensibility, 55 
Epidemic paralysis, 388 
Epigastric reflex, 35 
Epilepsia partialis continua, 649 

procursiva, 647 

tarda, 813 
Epilepsy, 639 

attack of, 642. See also Epileptic 
attack. 

aurae of attacks of, 643 

complete convulsion of, 644 

continuous, 649 

diagnosis of, 649 
differential, 650 

ecstasy in, 627 



INDEX. 



919 



Epilepsy, etiology of, 640 
general state in, 649 
in etiology of insanity, 719 
inciting causes of, 640 
myoclonus, 648 
nocturnal, 645 
pathology of, 641 

postparoxysmal phenomena of, 648 
prodromes of attacks of, 642 
prognosis of, 651 
status epilepticus in, 646 
treatment of, 652 
uncinate fits, 643 
vertiginous attacks in, 646 
Epileptic attack, 642 
aurse of, 642 
cerebral, 644 
motor, 643 
psychic, 643 
sensory, 643 
clonic period of, 645 
complete, 644 

in infantile cerebral palsies, 256 
incomplete, 646 
period of stertor, 645 
psychic equivalents of, 647 
tonic stage of, 644 
vertiginous, 646 
dementia, 853 
insanity, 851 

acute transitory, 854 
chronic, 855 
diet in, 858 

moral treatment of, 856 
treatment of, 855 
Epileptics, psychic degeneration of, 853 
Epistaxis after middle life, 205 
Erb's paralysis, 423 
phenomenon, 538 
Ergot in acute spinal leptomeningitis, 283 
in caisson disease, 382 
in spinal meningeal hemorrhage, 286 
in tabes dorsalis, 462 
Ergotism, 476 

Eruption in leptomeningitis, 84 
Erythromelalgia, 331 
Eserin in myoclonia, 573 
Esmarch's bandage in Raynaud's dis- 
ease, 542 
Esophagismus, 141 
Esthesiometer, 51 
Eucain in tetanus, 555 
Ewald's labyrinthine test, 138 
Exalgin in chorea, 569 
Exaltation, 738 

Examination in insanity, methods, 756, 
761 
in nervous diseases, 17 
Exophthalmic goiter, 523 
blood in, 526 

cardiovascular symptoms of, 526 
course and progress of, 531 
diagnosis of, 531 
digestive disturbances in, 530 
etiology of, 523 
genital disturbances in, 531 
goiter in, 527 



Exophthalmic goiter, hemorrhage in, 529 

mental disturbances in, 529 

morbid anatomy of, 525 

motor symptoms of, 528 

muscles in, 526 

ocular symptoms of, 527 

respiratory changes in, 530 

secretory symptoms of, 529 

skin in, 530 

symptoms of, 526 

tables of, 531 

treatment of, 532 

vasomotor symptoms of, 529 
Exothyropexy, 533 
Extension symptoms, 194 
Extrapial hemorrhage, 76 
Eyes, anomalies of, 705 
Eye-strain, influence of, 63 

Face, center for movements of, 171 
Facial asymmetry, 699 

expression in insanity, 759, 760 
hemiatrophy from disease of trifacial 

nerve, 120 
length, 696, 699 
nerve, 123 

anatomical considerations of, 123 
paralysis of, 125. See also Facial 
paralysis. 
spasmodic affections of, 124 
paralysis, 125 
alternating, 132 
course of, 128 
diagnosis of, 124 
double, 138 
nuclear, 131 

peripheral, etiology of, 125 
prognosis of, 130 
supranuclear, 132 
symptoms of, 126 
treatment of, 131 
spasm, 124 
Facioscapulohumeral form of muscular 

atrophy, 423 
Falling sickness, 639 
Family ataxia, 468 
course of, 474 
diagnosis of, 474 
etiology of, 470 
Friedreich's form of, 474 
Marie's form of, 474 
morbid anatomy of, 470 
prognosis of, 475 
symptoms of, 471 
treatment of, 475 
varieties of, 474 
chorea, 570 

history in insanity, 758 
myotonia, 580 
periodic paralysis, 583 
tremor, 584 
Faradic current, test with, in health, 42 
Fatigue neuroses, 585 
Fever, hysterical, 634 
Fibrillar neuromata, 294 
Fibrillary chorea, 572 
tremor, 30 



920 



INDEX. 



Fibroma of brain, 262 

Fibular point, 312 

Field of vision, 64. See also Visual field. 

Fifth nerve. See Trifacial nerve. 

Finger, center for movements of, 171 

First cranial nerve. See Olfactory nerve. 

Fixed point, 64 

Flat-foot in intermittent limping, 544 

in tabes, 452 
Flat headedness, 695 
Flat-roofed palate, 701, 703 
Flavor, 66 

Flexibilitas cerea, 743, 750 
Flexner's serum in acute spinal lepto- 
meningitis, 283 
in diplococcus variety of meningitis, 

90 
in leptomeningitis, 88 
Flight of ideas in dementia praecox, 804 
Fly-blister in leptomeningitis, 88 
Foerster's method of division of nerve- 
roots in cerebral palsies of children, 257 
Folie, 679 

a deux, 724 

du doute, 748 

imposee, 724 

simultanee, 724 
Foot-clonus, 37 

Foot-drop in multiple neuritis, 320, 321 
Forced movements in cerebellar disease, 
193 
in disease of labyrinth, 66 

positions in cerebellar disease, 193 
Forgetfulness in multiple neuritis, 327 
Formes frustes in multiple sclerosis, 486 
Fourth nerve, anatomical considerations 
of, 109 
effect of division of, 110 
Fowler's solution in chorea, 569 
Freud's views on dreams, 766 
Friedreich's ataxia or disease, 469. See 

also Family ataxia. 
Froehlich's dystrophia adiposogenital, 

503 
Frontal lines, 175 
Front-tap contraction, 37 
Functional nervous diseases, 501 

stigmata of degeneracy, 22 
Furor epilepticus, 739 



Gait, importance of, in diagnosis, 28 

in family ataxia, 472 

in idiopathic muscular atrophy, 420 

in multiple neuritis, 320 
sclerosis, 482 

in Parkinson's diseases, 577 

in sciatic neuritis, 312 

paraplegic, 374 
Galvanic current, test of muscle by, in 

health, 45 
Galvanometer test for emotions, 764 
Ganglion neuroma, 294 
Gastralgia, 150 

Gastric branches of vagus, diseases of, 
150 

crises, 445 



Gastrodynia, 150 

Gastro-intestinal disorders in etiology of 

insanity, 718 
General convulsions, 32 

paralysis of the insane, 813. See also 
Paralytic dementia. 

paresis, 813. See also Paralytic de- 
mentia. 
Geniculate bodies, lesion of, 105 
Genital disease in etiology of insanity, 718 

dystrophy, 510 

organs, anomalies of, 711 
Genito-urinary function, anomalies of, 
713 

tract, examination of, 26 
Giant swelling, 545 

urticaria, 545 
Gigantism, 509 

Girdle sensation in tabes dorsalis, 439 
Glabellar point, 174 
Glioma of brain, 259 

of spinal cord, 383 
Globus, 141 

hystericus, 622 
Glossopharyngeal nerve, anatomical con- 
siderations of, 140 
diseases of, 140 
Gluteal nerve, lesions of, 309 

point, 312 
Glycosuria in acromegalia, 508 

in insanity, 755 
Goiter, exophthalmic, 523. See also 

Exophthalmic goiter. 
Gothic palate, 701 
Gowers' rule in testing diplopia, 112 
Grandeur, delusion of, 746 
Graphic-motor aphasia, 183 
Graphospasmus, 585 
Graves' disease, 523. See also Ex- 
ophthalmic goiter. 
Gray matter of cord, lesions of, 388 



Habit spasm, 606 

Habitat, importance of, in diagnosis, 20 
Habits, investigation of, 19 
Hallucinations, 729 

conditions in which they occur, 732 

effect of, on actions, 749 

examination for, 731 

of memory, 742 

origin of, 731 
Hallucinatory agitation, 750 

confusion, 732 

stupor, 732 
Hallucinosis, alcoholic, acute, 715 
Hammer-toe, 310 

in family ataxia, 473 
Hand-dynamometer of Mathieu, 28 
Hand-writing, examination of, 69 

in chorea, 564 

in motor aphasia, 181 
Harelip, 705 

Hashish in etiology of insanity, 716 
Head injuries in etiology of insanity, 720 

retraction of, in cerebellar disease, 193 

tetanus, 554 



INDEX. 



921 



Headache as cerebral symptom, 196 

in brain abscess, 246 
lesions, 196 
tumors, 264 

in cerebral syphilis, 491 

in encephalic syphilis, 494 

in epilepsy, 644 

in leptomeningitis, 81 

in lesions of cerebellum, 193 

in migraine, 655 

in neurasthenia, 594 

in pial hemorrhage, 78 

in tubercular leptomeningitis, 93 
meningitis, 93 

in tumor of brain, 264 

lead cap, 594 

occipital, in cerebellar disease, 193 

sick, 653 
Health, electrical tests in, 42 
Hearing, affections of, 133 
in leptomeningitis, 83 

center for, 173 

electrical testing of, 49 

hallucinations of, 730 

illusions of, 733 

in facial paralysis, 128 

in idiocy, 870 

testing of, 65 
Heart disease in etiology of insanity, 718 
Hebephrenic form of dementia praecox, 
807 

insanity, 722 
Hebetude from tumors in corpus cal- 

losum, 188 
Heboidophrenia, 807 
Heel-tendon reflex, 37 
Heine-Medin's disease, 388 
Hematoma auris, 753 

of dura mater, 74 
Hematomyelia, 362 

diagnosis of, 364 

etiology of, 362 

morbid anatomy of, 363 

prognosis of, 364 

symptoms of, 363 

treatment of, 364 
Hemianesthesia in cerebral hemorrhage, 

214 
Hemianopic pupillary reaction, 104 
Hemianopsia, double homonymous, ex- 
planation of production of, 103 

explanation of production of, 101 

from cerebral hemorrhage, 214 

in tumor of brain, 266 
Hemiatrophy, facial, from disease of 

trifacial nerve, 120 
Hemicordal lesion, effect of, on sensa- 
tion, 56, 57 
Hemiplegia, 29, 215 

associated movements in, 215 

causes of, 215 

circulatory disturbances in, 217 

complications of, 218 

contractures in, 215 

from cerebral hemorrhage, 213 

gait in, 216 

hemianesthesia in, 217 



Hemiplegia, hysterical, 629 
in brain-tumor, 266 
in central softening, 227 
in cerebral palsies of children, 250 
position of upper extremity in, 217 
Hemiplegic gait, 216 

state, 215. See also Hemiplegia. 
Hemorrhage, cerebellar, 220 
cerebral, 209 

apoplectic state in, 212 
clinical forms of, 219 
course of, 218 
diagnosis of, 220 
differential diagnosis of, 220 
etiology of, 211 
hemiplegia from, 215 
pathological anatomy of, 210 
prognosis of, 221 
sensory disturbances in, 214 
symptoms of, 212 
treatment of, 222 
trophic disturbances in, 214 
extradural spinal, 284 
extrapial, 76 

into spinal cord, 362. See also Hema- 
tomyelia. 
into tumor of brain, 267 
intrapial, 77 
meningeal, 76 
pial, 76 

spinal meningeal, 284 
diagnosis of, 285 
etiology of, 284 
morbid anatomy of, 285 
prognosis of, 286 
symptoms of, 285 
treatment of, 286 
subdural spinal, 284 
Hereditary cerebellar ataxia, 469 
cerebrospinal syphilis, 498 
degeneracy, 691 
spastic paraplegia, 475 
prognosis of, 476 
symptoms of, 475 
treatment of, 475 
tropho-edema, chronic, 552 
Heredity in etiology of insanity, 689 

neurotic importance of, 18 
Herpes labialis in leptomeningitis, 83 
zoster, 337 

degeneration in peripheral nerves in, 
338 
spinal cord in, 338 
diagnosis of, 339 
distribution of, 339 
etiology of, 337 
pathology of, 338 
symptoms of, 338 
treatment of, 339 
Herpetiform morphea, 534 
Heterophoria, 63 
Hiccup, 147 

Hide-bound disease, 534 
Hip-roofed palate, 701, 704 
History, family, in insanity, 758 

of patient in insanity, 758 
Horizontal localization of cord-lesions, 351 



922 



INDEX. 



Hot-baths in combined sclerosis of cord, 
466 

in leptomeningitis, 87 

in multiple neuritis, 336 

in tubercular leptomeningitis, 96 
Huntington's chorea, 570 

disease, 570 

diagnosis of, 571 
etiology of, 570 
morbid anatomy of, 570 
symptoms of, 571 
Hutchinson's teeth, 705 
Hydrocephalic cry, 93 
Hydrocephalus, 273 

acute, 91. See also Leptomeningitis, 
tubercular. 

course of, 275 

diagnosis of, 275 

etiology of, 273 

external, 273 

internal, 273 

morbid anatomy of, 273 

prognosis of, 276 

symptoms of, 274 

treatment of, 276 
Hydromyelocele, 387 
Hydrophobia, 556 

diagnosis of, 557 

morbid anatomy of, 556 

Negri bodies in, 556 

symptoms of, 556 

treatment of, 558 
Hydrotherapy in exophthalmic goiter, 
532 

in insanity, 774 

in psychasthenia, 605 
Hyoscin in epilepsy, 858 

in etiology of insanity, 716 

in mania, 789 

in mental disease, 777 

in myoclonia, 573 

in Parkinson's disease, 580 

in senile dementia, 813 

in torticollis, 152 
Hyoscyamin in epilepsy, 858 

in etiology of insanity, 716 

in mania, 789 

in mental disease, 777 
Hyperacusis, 133 
Hyperageusia, 67 
Hyperalgesia, 55 

in mental disease, 734 

in tabes dorsalis, 440 
Hyperemia, cerebral, 202. See also 

Cerebral hyperemia. 
Hyperesthesia, 55 

auditory, 65, 133, 134 

from lesions of spinal cord, 349 

hysterical, 619 

in mental disease, 734 

in multiple neuritis, 325 
Hyperhedonia, 735 
Hyperostosis cranii, 548 
Hyperpituitarism, 502 
Hyperthyroidation, 524 
Hypertonus of muscles, 32 
Hypertrophic trophoneuroses, 548 



Hypertrophies, localized, 550 

unsymmetrical, 552 
Hyphedonia, 735 
Hypnotism, 674 

in insanity, 780 

in treatment of hysteria, 638 

methods of inducing, 674 

uses of, 675 
Hypnotizing, methods of, 674 
Hypochlorhydria in insanity, 754 
Hypochondriacal melancholia, 790 

paralysis, 752 
Hypochondriasis, 745 

effect of, on actions, 751 

senile, 812 
Hypoglossal nerve, anatomical condi- 
tions of, 154 

paralysis, 155 

spasms, 154 
Hypoglossus, affections of, in leptomen- 
ingitis, 83 
Hypomania, 787 

Hypophysis cerebri, overactivity of, 502 
trophoneuroses related to, 502 
underactivity of, 502 
Hypopituitarism, 502 
Hypotonus of muscles, 32 
Hysteria, 610, 851 

aboulia in, 621 

accidents in, 621 

achromatopsia in, 615 

agraphia in, 632 

amnesia in, 610, 620 

anesthesia in, 613 
distribution of, 616 
peculiarities of, 617 

angina pectoris in, 632 

anorexia in, 633 

anuria in, 633 

aphonia in, 632 

arc de cercle in, 624, 625 

astasia abasia in, 630 

attacks of ecstasy in, 627 
of sleep in, 627 

aura of, 622 

cephalalgia in, 631 

clonic phase of, 622 

contractures of, 628 

cough in, 630, 632 

course of, 635 

coxalgia in, 630 

dermographism in, 635 

diagnosis of, 636 

digestive apparatus in, 633 

dyschromatopsia in, 614 

dysphagia in, 633 

dyspnea in, 633 

epileptoid attacks in, 627 
period of, 622 

etiology of, 621 

fever of, 634 

globus in, 122, 627 

grand attacks of, 622 

hearing in, 614 

hemiplegia in, 629 

hyperesthesia in, 619 

impressionability in, 621 



INDEX. 



923 



Hysteria in etiology of insanity, 719 
modified attacks of, 626 
monoplegia in, 629 
motor accidents of, 628 
movements in, 619 
muscular atrophy in, 635 
nodding spasm in, 630 
paralysis of, 628 
period of clownism, 623 

of delirium, 626 

of passional attitudes, 625, 626 
phase of contortions of, 625 

of grand movements of, 625 

of resolution of, 623 
prognosis of, 636 
ptosis in, 629 

pulmonary congestion in, 632 
reflexes in, 617, 618, 628 
respiratory affections in, 627 
rhythmical spasms in, 630 
saltatory chorea in, 630 
sensory accidents of, 631 
simulation in, 621 
smell in, 614 

somnambulic attacks in, 627 
spasmogenic zones in, 619 
special senses in, 614 
spinal irritability in, 632 
stigmata of, 613 

mental, 620 

motor, 619 

sensory, 613 
symptoms of, 612 
syncopal attacks of, 627 
taste in, 614 
tetanic attacks in, 626 
tics in, 631 
tonic phase of, 622 
torticollis in, 629 
trance in, 627 
treatment of, 637 

general, 637 

special, 638 
tremors in, 631 
trophic accidents of, 634 
tympanites in, 633 
urinary apparatus in, 633 
vasomotor accidents of, 635 

change in, 613 
vertiginous attacks in, 627 
visceral accidents of, 632 

neuralgias in, 632 
vision in, 614 
Hysterical anesthesia, 57, 613 

distribution of, 616 

peculiarities of, 617 
breast, 635 
contractures, 628 
fever, 634 
hyperesthesia, 619 
insanity, 851 
paralysis, 752 
pseudomeningitis, 631 
tics, 631 
tremors, 631 
Hysterogenic point or zone, 619 
Hysteroneurasthenia, 599, 658 



Ice in myelitis, 372 
Ice-bag in leptomeningitis, 87 
in meningeal hemorrhage, 286 
in sciatic neuritis, 315 
in spinal leptomeningitis, 283 
Idea-association, actions induced by dis- 
orders of, 750 
disorders of, 740 
Ideas, accelerated flow of, 742 
defective evolution of, 736 
diminished flow of, 733 
disorders of, 735 
imperative, 765 
Idiocy, amaurotic family, 255, 859 
attention in, 872 
civility and politeness in, 876 
classification of, 859 
clothing in, 908 

consciousness and personality in, 885 
defined, 859 
destructiveness in, 876 
diagnosis of, 891 
education of attention in, 901 

of eye in, 902 

of hands in. 903 

of hearing in, 902 

of sense of touch in, 901 

of taste and smell in, 902 
food in, 908 
general etiology of, 867 

pathological anatomy of, 885 

symptomatology of, 870 

treatment of, 900 
hearing in, 870 
hydrotherapy in, 907 
instincts in, 884 
intelligence in, 881 
language in, 879 

manual and industrial training in, 905 
masturbation in, 908 
medical treatment of, 907 
Mongolian, 866 
moral training in, 906 
morbid movements in, 870 
muscular sensibility in, 870 
organic sensations in, 872 
personality in, 894 
physical culture in, 907 
physiognomy in, 878 
play in, 876 
preoccupation in, 874 
prognosis of, 906 
psychological evolution in, 885 
reflection in, 874 
responsibility in, 884 
right-and-left-handedness in, 871 
sentiments in, 876 
sight in, 869 
smell in, 870 
special aptitudes in, 875 
surgical treatment of, 907 
tactile pain in, 870 
taste in, 870 
teaching of cleanliness in, 903 

language in, 904 

to walk in, 903 
thermic sensibility in, 870 



924 



IXDEX. 



Idiocy, traumatic, 866 

voluntary movements in, 872 

will in, 884 
Idiopathic muscular spasm, 38 

progressive muscular atrophy, 414. 
See also Progressive muscular atro- 
phy. 
Idiots, education of, 900 

savants, 866 
Iliac point, 313 
Illness, the examination of, 20 
Illusions, 733 

origin of, 734 
Imitation in etiology of insanity, 724 
Imperative ideas, 747 
Inanition delirium, 718 
Incoherence, 743 
Incontinence, urinary, 23 
Incoordination, detection of, 30 
Incubus, 671 

Indicanuria in insanity, 755 
Indifferent electrode, 42 
Indiscriminate cord-lesions, 362 
Infantile cerebral palsies, 248. See also 
Cerebral palsies of children. 

type of muscular atrophy, 423 
Infant ilism, 518 
Infection neuroses, 553 
Infective sinus thrombosis, 236. See 

also Sinus thrombosis. 
Inflammation of brain, 240 

of nerves, 289. See Neuritis. 
Inflammatory sinus thrombosis, 236 
Ingravescent apoplexy, 219 
Inherited syphilis as a predisposing cause 

to nervous disease, 18 
Insane, asylums for, 708 

ear, 743 

isolation of, 770 

moral treatment of, 778 
Insanity, 679 

accompanying physical diseases of, 751 

acute treatment of, 772 

age in, 699 

alcohol in etiology of, 714 

attitude in, 759 

behavior in, 759 

chronic delusional, 827. See also 
Paranoia. 

circular, 794. See also Circular in- 
sanity. 

classification of, 681 

commotion, 720 

definition of, 679 

diet in, 774 

disorders of sensation in, 729 

drugs in, 777 

electrotherapy in, 776 

epileptic, 851 

acute transitory, 854 
chronic, 855 
treatment of, 855 

etiologv of, atheromatous arteries in, 
718 
atropin in, 716 
carcinoma in, 718 
cocain in, 716 



Insanity, etiology of, epilepsy in, 719 

exhaustion in, 721 

gastro-intestinal disorders in, 718 

genital disease in, 718 

hashish in, 716 

head injuries in, 720 

heart disease in, 718 

hysteria in, 719 

imitation in, 724 

infections in, 718 

menopause in, 722 

metallic poisons in, 717 

morphin in, 715 

nephritis in, 718 

organic nervous disease in, 719 

physiological factors in, 721 

puberty in, 721 

puerperal state in, 722 

senility in, 723 

syphilis in, 717 

tuberculosis in, 718 

various poisons in, 717 
examination in, methods, 756, 761 
general etiology of, 689 

symptomatology of, 728 

treatment of, 767 
hebephrenic, 722 
heredity in, 689 
hydrotherapy in, 774 
hypochlorhydria in, 754 
hysterical, 851 
manic-depressive, 781. See also Manic- 

depressive insanity. 
mannerisms in, 760 
massage in, 774 
menstruation in, 755 
moral causes of, 723 
motor disorders in, 752 
paralyses in, 752 
physiognomy in, 759 
progressive systematized, 827 
prophylaxis of, 769 
psychotherapy in, 771 
reciprocal, 724 
reflex disorders of, 753 
rest-cure in, 773 
secretory disorders in, 753 ] 
sensory disorders in, 752 
sex in, 689 
strain in, 714 

temperature changes in, 755 
toxic influences in, 714 
traumatic. 720 
trophic disorders in, 753 
urine in, 754 
vascular disorders in, 756 
Insomnia, 668 
etiology of, 668 
symptoms of, 668 
treatment of, 669 
Insular sclerosis, 479. See also Multiple 

cerebrospinal sclerosis. 
Integument, examination of. 25 
Intelligence, testing of, 763 
Intention tremor, 30 

in multiple sclerosis, 483 
Intermittent limping, 543 



INDEX. 



925 



Intermittent limping, treatment of, 544 

mania, 787 
Intermittirende Hinke, 543 
Internal capsule, function of, 186 

lesions of, effect of, on sensation, 57 
motor paths in, 186 
sensory paths in, 186 
Intrapial hemorrhage, 77 
Intrapsychic ataxia, 806 
Invasion symptoms, 194 
Involution melancholia, 799 
course of, 801 
prognosis of, 801 
symptoms of, 800 
treatment of, 801 
Iodid of potassium in bronchial asthma, 

146 
Iodids in cerebral hemorrhage, 223 
in cerebrospinal syphilis, 498 
in intermittent limping, 544 
in leptomeningitis, 88 
in neuritis, 293 
Iodoform, injection of, within dura in 
tubercular leptomeningitis, 96 
ointment for leptomeningitis, 88 
Iridoplegia, 63 
Iron in chorea, 569 

in multiple neuritis, 336 
in neurasthenia, 601 
Irradiation, 737 
Irresein, 679 
Irritability, 739 
Irritative brain-lesions, 194 
Irrsinn, 679 
Isolation of insane, 770 



Jacksonian convulsions, 32 
in cerebral softening, 227 

fits, 573 
Jaw-jerk, production of, 34 
Jendrassik's method of reinforcing knee- 
jerk, 36 
Joints, Charcot, 40, 451 

motility of, in infantile cerebral pal- 
sies, 252 

testing sensibility of, 54 

trophic disorders of, 40 
Judgment, weakness of, 748 
Jumpers, 608 
Juvenile atrophy, 423 

tabes, 457 

variety of idiopathic muscular atrophy, 
423 



Kakidrosis, 787 

Kakke, 317, 331 

Keel-shaped skull, 696 

Kernig's sign in leptomeningitis, 82 

in tetanus, 553 
Knee-jerk, 36 

reinforced by Jendrassik's method, 36 
Kocher's ventil operation in idiocy, 907 
Koch's bacillus in leptomeningitis, 79 
Korsakoff's psychosis, 715 
senile, 812 



Lability of phenomena, 740 
Labioglossolaryngeal paralysis, 159. See 
also Polioencephalitis inferior chronica. 
Labyrinth tests, 138 
Labyrinthial disturbance in tabes, 445 
Lachrymal reflex in hysteria, 616 
Lalling, 68 

Landholt's rule in testing diplopia, 111 
Landouzy-Dejerine type of muscular 

atrophy, 423 
Landry's paralysis, 376 
course of, 379 
diagnosis of, 379 
etiology of, 377 
morbid anatomy of, 378 
prognosis of, 379 
symptoms of, 378 
treatment of, 379 
Laryngeal crisis, 448 
epilepsy, 144 
muscles, action of, 142 
nerves, 141 
palsies in tabes, 448 
paralyses, 142 
abductor, 142 
adductor, 142 
complete bilateral, 144 
diagnosis of, 142 
of tensors, 143 
treatment of, 144 
spasm, 144 
stroke, 448 
Larvnx, anesthesia of, 144 
Latah, 608 

Latent lesions of cerebral cortex, 173 
Lateropulsion, 577 
Lathyrism, 476 
Law of regression, 736 
Lead in etiology of insanity, 717 
Lead-cap, headache, 594 
Lead-palsy, 329 
prognosis of, 334 
treatment of, 335 
Leg sign in tetanv, 539 
Length-breadth index, 696, 699 
Lenticular degeneration, progressive, 189 
Leontiasis ossea, 548 
Leprosy, Asturian, 476 
Leprous neuritis, 332 
Leptocephalus, 695 
Leptomeningitis, 78 
acute, spinal, 280 
course of, 282 
diagnosis of, 282 
etiology of, 280 
morbid anatomy of, 281 
Osier's classification of, 79 
prognosis of, 283 
symptoms of, 281 
treatment of, 283 
chronic, 98 
spinal, 284 

morbid anatomy of, 284 
prognosis of, 284 
symptoms of, 284 
treatment of, 284 
course of, 84 



926 



INDEX. 



Leptomeningitis, diagnosis of, 85 
diplococcus variety, 90 
etiology of, 78 
headache in, 81 
Kernig's sign in, 82 
lumbar puncture in, 89 
pathological anatomy of, 80 
prognosis of, 86 
symptoms of, 81 
treatment of, 87 
tubercular, 91 
course of, 95 
diagnosis of, 95 
etiology of, 91 
headache in, 93 
pathological anatomy of, 91 
prognosis of, 96 
pupils in, 94 
symptoms of, 92 
treatment of, 96 
varieties of, 90 
Lesions of one-half of cord, effect of, 56 
of spinal cord, anesthesia in, 55 

combined, in anemias and ca- 
chexias, 466 
Leukomyelitis, posterior, 428. See also 

Tabes dor salts. 
Lids, examination of, 62 
Ligaments, trophic disorders of, 40 
Lightning pains in tabes dorsalis, 438 
Limbs, anomalies of, 713 
Limp chorea, 567 
Limping, intermittent, 543 

treatment of, 544 
Lingual spasm, 154 
Lipoma of brain, 262 
Lipomatosis, symmetrical, 550 
Lips, anomalies of, 705 
Litigation psychosis, 659 
Little's disease, 254 
Local asphyxia, 540 
convulsions, 32 
death, 540 
syncope, 540 
Localization, cerebral, 167 

general considerations of, 167 
in cerebral cortex, 167 
motor cortical, 169 
of cord-lesion, horizontal, 351 

vertical, 347 
of lesions of cauda equina, 360 
sensory cortical, 172 
spinal, 340 
Localized hypertrophies, 550 

symptoms, 195 
Lockjaw, 553 
Locomotor ataxia, progressive, 428. See 

also Tabes dorsalis. 
Logorrhea, 739 
Lumbar points, 313 
puncture, 27 

in leptomeningitis, 89 
in serous meningitis, 98 
in spinal leptomeningitis, 283 
in tubercular meningitis, 97 
Lyssa, 556 
Lyssophobia, 557 



Macrocephalus, 695 

Macroglossus, 705 

Magnesium sulphate in chorea, 569 

in tetanus, 555 
Make of current, 42 
Maladie des tics, 606, 748 
Mandibular muscles, paralysis of, from 
disease of trifacial nerve, 120 
reflex, 34 
Mania, 784 

acute delirious, 787 
course of, 788 
diagnosis of, 788 
distractibility in, 785 
etiology of, 783 
intermittent, 787 
mitis, 787 
periodic, 787 
prognosis of, 784 
reasoning, 787 
recurrent, 787 
senile, 812 
transitory, 787 
treatment of, 788 
unproductive, 782 
varieties of, 787 
Manic stupor, 782 
Manic-depressive insanity, 781 

circular type, 784. See also Circular 

insanity. 
classification of, 783 
depressive phase, 789. See also 

Melancholia. 
etiology of, 783 

manic phase, 783. See also Mania. 
prognosis of, 784 
Marantic sinus thrombosis, 235. See 

also Sinus thrombosis. 
Massage in anterior poliomyelitis, 397 
in combined sclerosis of cord, 466 
in exophthalmic goiter, 532 
in facial paralysis, 131 
in infantile cerebral palsies, 257 
in insanity, 774 
in intermittent limping, 544 
in Landry's paralysis, 380 
in multiple neuritis, 336, 337 
in myelitis, 372 
in neuritis, 293 

of brachial plexus, 308 
in psychasthenia, 605 
in sciatic neuritis, 316 
in spinal muscular progressive atrophy, 

414 
in tabes dorsalis, 460 
Massive type of acromegalia, 509 
Masticatory paralysis, 119 

spasm, 119 
Mastoid disease, importance of, 66 
Masturbation in insanity, treatment of, 

781 
Mathieu's hand-dynamometer, 28 
Maximal points of pain, 58 
Median nerve, lesions of, 301 
Medulla oblongata, symptoms of lesions 

of, 191 
Megalocephalie, 548 



INDEX. 



927 



Megalodactyl, 711 
Megalomelus, 711 
Melancholia, 789 
agitata, 743, 800 
anxiosa, 800 
attonita, 743 
course of, 792 
diagnosis of, 792 
hypochondriacal, 790 
involution, 799. See also Involution 

melancholia. 
passiva, 743 
prognosis of, 784 
senile, 812 
simplex, 800 
stuporosa, 801 
treatment of, 793 
varieties of, 792 
Memory defects, actions induced by, 749 
"disorders of, 741 
importance of, in diagnosis, 23 
testing of, 762 
Memory-pictures, disorders of, 735, 736 
Memory-store, 742 
Meniere's disease, 136. See also Aural 

vertigo. 
Meningeal hemorrhage, 747 

spinal, 284 
Meninges, cerebral, 72 

spinal, tumors of, 280 
Meningitis, acute cerebral, 78. See also 
Leptomeningitis and Pachymenin- 
gitis. 
serous, 80 
basilar, 91. See also Leptomeningitis, 

tubercular. 
cerebral, syphilitic, 489 ~ 

symptoms of, 493 
cerebrospinal, 78. See also Lepto- 
meningitis. 
chronic infantile, 97 
diplococcus variety, 90 
course of, 90 , 
diagnosis of, 90 
etiology of, 90 
prognosis of, 90 
symptoms of, 90 
treatment of, 90 
externa serosa, 97 
interna serosa, 97 

purulent, 78. See also Leptomeningi- 
tis. 
serosa spinalis circumscripta, 384 
serous, 97 
course of, 98 
diagnosis of, 98 
etiology of, 97 
pathology of, 97 
symptoms of, 97 
treatment of, 98 
spinal, 278 

syphilitic spinal, 495 "* 
Meningocele, 387 
Meningomyelitis, spinal, 278 

syphilitic, 495 
Meningomyelocele, 387 
Menopause in etiology of insanity, 722 



Menstruation in insanity, 755 
Mental condition of patient, examination 
m of, 22 

diseases, 679 

disturbance as a cerebral symptom, 196 

strain, 713 

symptoms in tumor of brain, 265 

torticollis, 152, 609 
Meralgia paresthetica, 309 
Mercurial inunctions in acute spinal 
leptomeningitis, 283 
in neuritis, 293 
Mercury in cerebrospinal syphilis, 498 

in etiology of insanity, 717 

in hydrocephalus, 276 

in leptomeningitis, 88 

in sciatic neuritis, 315 

in tabes dorsal is, 459 
Merkfahigkeit, 742, 762 
Merycism, 151 
Mesocephalic head, 694 
Metallic poisons, insanity and, 717 
Metatarsalgia, 310 
Microcephalus, 695 
Micromania, 745 
Middle-ear disease, 66 
Migraine, 653 

course of, 656 

diagnosis of, 656 

etiology of, 653 

headache in, 655 

ophthalmoplegic, 654 

pathology of, 656 

prognosis of, 657 

symptoms of, 654 

treatment of, 657 
Mimic spasm, 606 
Mind-blindness, 69, 179 

lesion causing, 173 
Mirror-speech, 70 
Mirror-writing, 70 
Misophobia, 603 
Modal change, 46 
Mogigraphia, 585 
Mongolian idiocy, 866 
Monocular diplopia, 63 
Monomania, 827 
Monoplegia, 29 

in tumor of brain, 266 
Moods, 737 
Moral causes of insanity, 723 

treatment of insane, 778 
Morbus sacer, 639 
Morel ear, 707, 708 
Morphin in caisson disease, 382 

in chorea, 569 

in etiology of insanity, 715 

in leptomeningitis, 87 

in mental disease, 777 

in migraine, 657 

in neuralgia, 665 

in Raynaud's disease, 542 

in sciatic neuritis, 316 

in tabes dorsalis, 462 

in tetanus, 555 
Morphological stigmata of degeneracy, 21 
Morton's disease, 310 



928 



INDEX. 



Morvan's disease, 404 
Motility, 28 
increased, 30 
reduced, 28 
Motor aphasia, 180 

areas of pain, localization of, by elec- 
tricity, 49 
disorders in insanity, 752 
function, anomalies of, 712 
neuroses, 570 

points of face and neck, 42 
of lower extremity, 45-47 
of upper extremity, 43, 44 
tics, 602 

tracts of brain, 186-193 
Movement, hallucinations of, 730 
Movements, associated, 32 

postplegic, 31 
Multiple abscesses of brain, 244 
cerebrospinal sclerosis, 479 
bulbar symptoms of, 485 
cerebral symptoms of, 485 
course of, 485 
diagnosis of, 486 
etiology of, 479 
forms of, 485 
intention tremor in, 483 
morbid anatomy of, 481 
motor features of, 482 
prognosis of, 487 
reflexes in, 482 
sensory symptoms of, 484 
symptoms of, 482 
treatment of, 487 
trophic disturbances in, 485 
vertigo in, 485 
visual disturbances in, 485 
neuritis, 317. See also Neuritis. 

recurrent, 332 
neuromata, 294 
paralyses of cranial nerves, 156 
Muscles, electrical testing of, 41 
testing of power of, 28, 29 
trophic disorders of, 40 
Muscular sense, testing of, 54 
spasm, idiopathic, 38 
system, examination of, 28 
Musculospiral nerve, lesions of, 299 
Mutism, 761 

in dementia prsecox, 805 
in hysteria, 68 
Myasthenia gravis,' 164 
Myasthenic reaction, 1 ? 49 
Myelinic neuromata, 294 
Myelitis, 365 

acute bulbar, 164 

syphilitic, 496 
atrophy in, 368 
central, 366 
course of, 370 
diagnosis of, 370 

differential, 371 
disseminated, 366 
etiology of, 366 
morbid anatomy of, 366 
motor symptoms of, 368 
paraplegia in, 373 



Myelitis, prognosis of, 371 

reflexes in, 368 

sensory symptoms of, 368 

symptoms of, 367 

transverse, 366 

treatment of, 372 

trophic changes in, 369 
Myelocele, 387 
Myoclonia, 571 

diagnosis of, 573 

etiology of, 572 

prognosis of, 573 

symptoms of, 572 

treatment of, 583 
Myoclonus, 571 

diagnosis of, 649 

epilepsy, 648 

prognosis of, 649 

treatment of, 649 
Myoidema, 38, 322 
Myoidism in tabes, 438 
Myopathic facies, 417 
Myopathy, primitive progressive, 414 
Myositis in multiple neuritis, 317 
Myotonia, 32, 590. See also Thomsen's 
disease. 

atrophica, 581 

congenita, 580 

family, 580 
Myotonic reaction, 48 
Myriachit, 608 
Mysophobia, 783 
Myxedema, 514 

acquired, of adults, 514 

congenital, 516 

etiology of, 519 

morbid anatomy of, 521 

operative, 516 

treatment of, 522 
Myxedematous idiocy, 516 

retardation, 518 



Narcolepsy, 672 

Narrow-headedness, 695 

Nasal crises in tabes, 445 

Naso-occipital arc, 681, 699 

Nasus aduncus, 706 

Negation, delusion of, 746 

Negativism in dementia prsecox, 805 

Negri bodies in hydrophobia, 556 

Neologisms, 761 

Neosalvarsan in tabes dorsalis, 459 

Nephritic crisis, 447 

Nephritis in etiology of insanity, 718 

Nerve, circumflex. See Circumflex nerve. 

divided, changes in, 287 
regeneration of, 288 
symptoms of, 287 
treatment of, 289 

division of, 287 

electric tests of, in health, 42 

median. See Median nerve. 

musculospiral. See Musculospiral nerve. 

phrenic. See Phrenic nerve. 

suprascapular. See Suprascapular 



INDEX. 



929 



Nerve, suture of, 289 

thoracic. See Thoracic nerve. 
ulnar. See Ulnar nerve. 
Nerve-grafting for neuromata, 296 
Nerves, cutaneous distribution of, 52, 53 
electrical testing of, 41 
inflammation of, 2S9. See also Neu- 
ritis. 
of lower extremity, lesions of, 308 
of trunk, lesions of, 308 
spinal. See Spinal nerves. 
Nerve-stretching for neuromata, 296 
Nerve-trunk, lesion of, anesthesia in, 55 
Nerve-tumors, 293. See also Neuro- 
mata. 
Nerve coughs, 145 

diseases, functional, 501 

organic, in etiology of insanity, 719 
dyspepsia, 151 

exhaustion, 592. See also Neuras- 
thenia. 
prostration, 592. See also Neuras- 
thenia. 
system, examination, in insanity, 761 
syphilis of, 487 
Neuralgia, 660 
characters of, 661 
conditions favoring, 661 
in branches of trifacial, 122 
in insanity, 752 
pathology of, 662 
treatment of, 664 
trifacial, 663 
varieties of, 663 
Neurasthenia, 592 

circulatory disorders in, 596 
course of, 599 
diagnosis of, 599 
disorders of hearing in, 596 
of smell in, 596 
of taste in, 596 
etiology of, 592 
fear in, 598 
forms of, 598 

gastro-intestinal disorders in, 596 
general state in, 598 
genital disorders in, 597 
headache in, 594 
mental disturbances in, 597 
motor disorders of, 593 
nosophobias in, 597 
photophobia in, 595 
prognosis of, 599 
secretory disorders in, 596 
sensory disturbances in, 594 
sleep in, 598 
symptoms of, 593 
tenderness in, 595 
traumatic, 658 
visual disturbances in, 595 
field in, 64 
Neuritis, 289 

adventitious, 290 
alcoholic, 329 
diagnosis of, 292 
etiology of, 289 
leprous, 332 

59 



Neuritis, migrans, 290 
morbid anatomy of, 289 
multiple, 317 

accommodation in, 326 
alcoholic form of, 33 
course of, 328 
diagnosis of, 333 

of the toxic cause of, 334 
differential diagnosis of, from hys- 
teria, 334 
from lead-poisoning, 329 
from locomotor ataxia, 333 
from myelitis, 333 
from pernicious anemias, 334 
from poliomyelitis, 333 
electrical changes in, 322 
etiology of, 317 
general conditions in, 326 
lesions in muscles in, 320 
in nerves in, 318 
of brain in, 319 
of spinal cord in, 319 
morbid anatomy of, 318 
motions of eyes in, 325 
nutrition in, 326 
prognosis of, 334 
pupils in, 325 
recurrent, 332 
reflexes in, 323 
special forms of, 328 
symptoms of, 320 
mental, 326 
motor, 320 
muscular, 320 
ocular, 325 
sensory, 324 
treatment of, 335 
trophic conditions in, 325 
vision in, 325 
of brachial plexus, 306 
causes of, 306 
diagnosis of, 307 
prognosis of, 307 
symptoms of, 306 
treatment of, 307 
of branches of trifacial, 122 
optic, 106 

as a symptom, 197 
parenchymatous, 290 
prognosis of, 292 
sciatic, 310 
causes of, 311 
diagnosis of, 314 
double, 314 

morbid anatomy of, 311 
symptoms of, 312 
tender points in, 312 
treatment of, 314 
symptoms of, 290 
syphilitic, 497 
treatment of, 292 
Neuroma of brain, 262 
Neuromata, 294 
amputation, 294 
amyelinic, 294 
cellular, 294 
diagnosis of, 295 



930 



INDEX. 



Neuromata, dolorosa, 294 

etiology of, 295 

fibrillar, 294 

ganglion, 294 

multiple, 294 

myelinic, 294 

prognosis of, 295 

symptoms of, 295 

traumatic, 294 

treatment of, 296 
Neuropsychoses, 851 
Neuroretinitis, 106 
Neuroses, 501 

classification of, 501 

fatigue, 585 

following traumatism, 658 

infection, 553 

motor, 570 

occupation, 20, 585, 591 
Neurotabes, 457 

Neurotic heredity in diagnosis, 18 
Nightmare, 671 
Night-terrors, 23, 671 
Ninth nerve. See Glossopharyngeal 

nerve. 
Nitrate of strychnin in spinal progres- 
sive muscular atrophy, 414 
Nitrite of amyl in bronchial asthma, 147 

in tetanus, 555 
Nitroglycerin in migraine, 657 

in sciatic neuritis, 315 
Nocturnal enuresis, 671 

epilepsy, 645 
Nodding spasm in hysteria, 630 
Normal child, development of the facul- 
ties of, 887 _ 
Nose, anomalies of, 706 
Nosebleed after middle life, 205 
Nutrition, abnormal variations in, 39 
Nystagmus, 115 



Oblique line, 175 

Obturator nerve, lesions of, 309 

Occupation neuroses, 20, 585, 591 

predisposing to nervous disease, 20 
Ocular muscle, spasms of, 115 
muscles, action of, 109 
nerves, anatomical considerations of, 
108 
diseases of, 108 
palsies, 110 
causes of, 114 
diagnosis of, 111 
location of lesion in, 113 
treatment of, 116 
Oculomotor apparatus, double cortical 

representation of, 109 
Olfactory nerve, diseases of, 100 
Oligodactyly, 711 
Oligomelus, 711 
Oliguria in insanity, 754 
Operative myxedema, 516 
Ophthalmic test in tubercular meningitis, 

96 
Ophthalmoplegia externa, 63 
interna, 63 



Ophthalmoplegia, progressive, 157. See 
also Polioencephalitis superior chronica. 

Ophthalmoplegic migraine, 654 

Ophthalmoscope, importance of, to neu- 
rologist, 63 

Ophthalmoscopic picture in amaurotic 
family idiocy, 253 

Opisthognathism, 697 

Opisthotonos in cerebellar disease, 192 

Opium in epilepsy, 653 
in insanity, 777 
in mania, 789 
in melancholia, 794 
in paralytic dementia, 826 
in Parkinson's disease, 580 
in torticollis, 152 

Opium-bromid treatment in epilepsy, 857 

Optic nerve, anatomy of, 101 
atrophy of, 40, 107 
diseases of, 101 
lesions of, 101, 106 
neuritis as a symptom, 197 

in tumors of brain, 265 
thalami, function of, 189 

lesions of, 105, 189 
tract, lesions of, 101-106 

Orbits, asymmetry of, 700 

Orientation, patient's, 762 

Orthognathism, 697 

Osier's classification of acute leptomen- 
ingitis, 79 

Osteo-arthropathie hypertrophiante 

pneumique, 549 

Osteo-arthropathy, hypertrophic, 549 

Osteoma of brain, 262 

Othematoma, 753 

Oxaluria in insanity, 754 

Oxycephalus, 695 



Pachydermatous cachexia, 514 
Pachymeningitis, 74 

cervicalis hypertrophica, 279 
externa, 74 

spinalis, 280 
hsemorrhagica, 74 
interna, 74 

course of, 74 

diagnosis of, 76 

etiology of, 74 

pathological anatomy of, 74 

spinalis, 279 

symptoms of, 75 

treatment of, 76 
Pain, areas of, visceral disease and, 58 
as a cerebral symptom, 197 
as a symptom, 57 
description of, by patients, 63 
in angina pectoris, 149 
in brain disease, 62 
in myelitis, 367 
in neuritis, 291 
in sciatic neuritis, 312 
in spinal tumors, 384 
in syphilitic meningitis, 496 
in tabes dorsalis, 438, 439 
maximal points of, 58 



INDEX. 



931 



Pain, sense, testing of, 51 
Palate, asymmetrical, 701, 704 

cleft, 702 

deformities of, 700 

dome-shaped, 701, 703 

flat-roofed, 701, 703 

Gothic, 701, 703 

hip-roofed, 701, 704 

with horseshoe arch, 701, 703 
Palpebral reflex, 33 
Palpitation, cardiac, 148 

in brain tumor, 198 
Palsies, combined, of nerves of arm, 304 

in tabes dorsalis, 437 

sleep, 673 
Palsy, Bell's, 125 

diver's, 380. See also Caisson dis- 
ease. 

scriveners', 585 

wasting, 407 
Panophthalmitis in leptomeningitis, 83 
Papilla, optic, diseases of, 105 
Papillitis, 105 

in tumor of brain, 265 
Papilloneuritis, 106 
Paradoxical contraction, 37 
Paraffin in facial hemiatrophy, 121 
Parageusia, 67 
Paragraphia, 69 
Paraldehyd in mania, 789 

in mental disease, 778 

in senile dementia, 813 
Paralysis, acute, ascending, 376. See 
also Landry's paralysis. 

agitans, 574. See also Parki?ison , s 
disease. 

beri-beric residual, 332 

Brown-Sequard, cord-lesion in, 56, 57 

bulbar, asthenic, 164 

cerebral, of children, 248 

chronic nuclear ocular, 157. See also 
Polioencephalitis superior chronica. 

diphtheric, 330 

epidemic, 388 

facial, 125. See also Facial paralysis. 

family periodic, 583 

from brain-abscess, 245 

from cerebral hemorrhage, 228 

from cord-lesion, 347 

hypoglossal, 155 

in anterior poliomyelitis, 392 

in cerebral softening, 227, 228 

in hysteria, 628 

in insanity, 752 

in multiple neuritis, 320 

in myelitis, 368 

in syphilitic meningitis, 496 

in tabes dorsalis, 437 

labioglossolaryngeal, 159. See also 
Polioencephalitis chronica. 

Landry's, 376 

laryngeal, 142. See also Laryngeal 
paralysis. 

masticatory, 119 

multiple, of cranial nerves, 156 

ocular, 110. See also Ocular palsy. 

of anterior crural nerve, 308 



Paralysis of auditory nerve, 134 
of circumflex nerve, 299 
of facial nerve, 125 
of median nerve, 302 
of musculospiral nerve, 300 
of obturator nerve, 309 
of phrenic nerve, 297 
of posterior thoracic nerve, 298 
of sciatic nerve, 309 
of spinal accessory nerve, 153 
of superior gluteal nerve, 309 
of suprascapular nerve, 299 
of tongue, 155 
pharyngeal, 141 
progressive bulbar, 159. See also 

Polioencephalitis inferior chronica. 
pseudobulbar, 164 
pseudohypertrophic, 423 
syphilitic spinal, 77 
ulnar, 303 
Paralytic chorea, 567 
dementia, 810, 813 

definition of, 813 

diagnosis of, 822 

differentiation of, from alcoholism, 
823 
from cerebrospinal syphilis, 824 
from multiple sclerosis, 825 
from neurasthenia, 823 

duration and prognosis of, 822 

etiology of, 814 

mental symptoms of, 817 

pathological anatomy of, 825 

physical symptoms of, 817 

prodromal period of, 816 

symptomatology of, 816 

terminal period of, 822 

treatment of, 826 
Paramimia, 69, 179 
Paramyoclonus, 581 

multiplex, 572 
Paramyotonia, congenital, 581 
Paranoia, 827 
alcoholic, 715 

course and prognosis of, 850 
definition of, 827 
erotica, 831 
etiology of, 828 
expansive period of, 831 
hallucinatoria acuta, 827 

chronica, 827 
inventoria, 831 
morbid anatomy of, 850 
periodica, 786 
persecutory period of, 829 
prodromal period of, 828 
querulans, 831 
reformat oria, 831 
religiosa, 831 
simplex acuta, 827 

chronica, 827 
symptomatology of, 828 
treatment of, 850 
varieties of, 827 
Paranoid form of dementia prsecox, 809 
Paraphasia, 178, 181 
Paraphrasia, 69 



932 



INDEX. 



Paraplegia, 29, 373. See also Paraplegic 
state. 
ataxic, 463 

syphilitic, 496 
from hematomyelia, 364 
hereditary spastic, 475. See also 

Hereditary spastic paraplegia. 
in myelitis, 373 
in spinal tumors, 384 
Paraplegic gait, 374 
state, attitude in, 375 
etiology of, 373 
gait in, 374 
in myelitis, 373 
prognosis of, 376 
reflexes in, 375 
symptoms of, 373 
treatment of, 376 
Parasyphilitic diseases, 499 
acquired, 500 
hereditary, 500 
nervous disease, 487 
Parathyroid glands, trophoneuroses re- 
lated to, 513 
Parenchymatous neuritis, 290 
Paresis, general, in cerebral hemorrhage, 

221 
Paresthesia in multiple neuritis, 324 

in neuritis, 290 
Paresthesias, 55 
Parkinson's disease, 574 
course of, 579 
diagnosis of, 580 
etiology of, 574 
mental state in, 579 
morbid anatomy of, 574 
muscular rigidity in, 576 
palsy in, 579 

sensory disturbances in, 579 
symptoms of, 575 
treatment of, 580 
trembling in, 577 
Past illness, investigation of, 19 
Patellar point, 313 

reflex, 36 
Pathological drunkenness, 715 
Patient, antecedents of, 18 
examination of, 17-71 
observation of, in insanity, 759 
Pavor nocturnus, 671 
Pellagra, 476 

treatment of, 478 
Pellarella, 476 

Percussion in brain disease, 197 
Periarteritis, cerebral, 204 
Perineuritis, 290 
Periodical mania, 787 

swelling, 545 
Peripheral nerves, trophic disease of, 40 

paralysis in insanity, 752 
Peroneal nerve, lesions of, 310 

variety of idiopathic muscular atrophy, 
423 
Persecution, delusion of, 745 
Personal history, 19 
Peterson's calipers, 697, 698 
Petit mal, 646 



Pharyngeal crises, 448 

paralysis, 141 
Pharyngeal reflex, 34 

spasm, 141 
Phenacetin in acromegalia, 509 
in epilepsy, 653 
in tabes dorsalis, 462 
Phocomelus, 711 
Phosphaturia in insanity, 754 
Photophobia as a symptom, 62 

in leptomeningitis, 82 
Phrenic nerve, lesions of, 297 
Physical examination, 24 

strain, 713 
Physiognomy of patient, 21 
Physiological factors in etiology of in- 
sanity, 721 
Pia mater, 750 

inflammation of, 78. See also Lep- 
tomeningitis. 
visceral, 72 
Pial hemorrhage, 76 

space, 72 
Pilocarpin in aural vertigo, 140 

in nervous deafness, 135 
Pirquet's test in tubercular meningitis, 96 
Pituitary extract in adiposis dolorosa, 513 
feeding in adiposis dolorosa, 513 
gland, 502 

tumor with acromegaly, 262 
with hydrocephalus, 273 
Plagiocephalus, 695 
Plantar nerve, external, lesions of. 310 
internal, lesions of, 310 
points, 313 
reflex, 37 
Platicephalus, 695 
Platysma, motor center for, 171 
Pneumococcus in leptomeningitis, 79 
Pneumogastric nerve. See Vagus. 
Polar change, 47 

Polioencephalitis, combined forms of, 164 
inferior chronica, 159 
course of, 162 
diagnosis of, 163 
etiology of, 159 
morbid anatomy of, 160 
symptoms of, 160 
treatment of, 163 
superior, acute, 159 
chronica, 157 
course of, 158 
diagnosis of, 158 
etiology of, 157 
pathological anatomy of, 157 
symptoms of, 157 
treatment of, 158 
Polioencephalomyelitis, 388 
Poliomyelitis, acute anterior, 388 
ascending form, 395 
course of, 395 
deformity in, 393, 394 
diagnosis of, 395 
etiology of, 388 
forms of, 395 
morbid anatomy of, 390 
prognosis of, 396 



INDEX. 



933 



Poliomyelitis, acute anterior, symptoms 
of, 392 
treatment of, 396 
chronic, 4Q7 
Polydactyly, 711 
Polymastia, 711 
Polyneuritis, 317. See also Neuritis, 

multiple. 
Polyuria in insanity, 754 
Pons Varolii, function of, 190 

symptoms of lesions of, 190 
Popliteal nerve, external, lesions of, 310 
internal, lesions of, 310 
point, 312 
Posterior columns of cord, effect of 
lesions of, 351 
horn of cord, effect of lesions of, 352 
roots of cord, effect of lesions of, 352 
spinal arteries, 346 
Posterolateral sclerosis, 463. See also 

Combined sclerosis of cord. 
Postplegic movements, 31 
Precordial anxiety, 738 

fright, 738 
Presenile paranoid condition, 813 
Present condition of patient, 24 
Pressure sense, testing of, 51 
Prodromes, epileptic, 642 
Prognathism, 697 

Progressive bulbar paralysis, 159. See 
also Polioencephalitis inferior chron- 
ica. 
general paralysis, 813. See also Para- 
lytic dementia. 
lenticular degeneration, 189 
locomotor ataxia, 428. See also Tabes 

dorsalis. 
muscular atrophy, 406 
idiopathic, 414 
course of, 422 
etiology of, 415 
morbid anatomy of, 416 
prognosis of, 425 
symptoms of, 417 
treatment of, 425 
varieties of, 423 
spinal, 406 
course of, 413 
diagnosis of, 413 
differential diagnosis of, 413 
etiology of, 407 
morbid anatomy of, 407 
prognosis of, 414 
symptoms of, 409 
treatment of, 414 
varieties of, 413 
with cord lesions. See Progres- 
sive muscular atrophy, spinal. 
without cord lesions. See Progres- 
sive muscular atrophy, idiopathic. 
dystrophy, 414 
ophthalmoplegia, 157. See also Polio- 
encephalitis superior chronica. 
spastic ataxia, 463. See also Com- 
bined sclerosis of spinal cord. 
systematized insanity, 827. See also 
Paranoia. 



Projectile vomiting as a symptom, 196 
Propulsion, 577 
Protopathic sensibility, 55 
Psammoma, 262 
Pseudo-apraxia, 744 
Pseudo-ataxia, 744 
Pseudoataxie cerebelleuse, 469 
Pseudobulbar paralyses, 164 
Pseudocerebral tumor, 269 
Pseudochorea, 744 
Pseudodementia, 740 
Pseudohypertrophic paralysis, 423 
Pseudomelia paresthetica, 218 
Pseudomeningitis, hysterical, 631 
Pseudoparalysis, congenital atonic, 424 
Pseudoparaphrasia, 744 
Pseudoparesis, syphilitic, 493 
Pseudotabes, 457 
Psvchanalysis, 764 
Psychasthenia, 598, 602 

course of, 604 

diagnosis of, 605 

etiology of, 604 

onset of, 604 

prognosis of, 605 

termination of, 605 

treatment of, 605 
Psychic degeneration of epileptics, 853 

equivalent of epileptic attack, 647 
Psycho-analysis in psychasthenia, 603 
Psychogenia, 851 
Psvchogeny, 851 
Psychopathy, 679 
Psychosis, 679 

alcoholic, 813 

Korsakoff's, 715 

litigation, 659 

senile, 810, 813 
Korsakoff's, 812 

traumatic, 659 
Psychotherapy, 771 
Ptosis as a symptom, 62 

sleep, 673 
Puberty in etiology of insanity, 721 
Puerperal state in etiology of insanity, 722 

tetanus, 554 
Pulmonary branches of vagus, affections 

of, 145 
Pulse in leptomeningitis, 83 

in polioencephalitis inferior chronica, 
162 

in spinal leptomeningitis, 284 

in tubercular leptomeningitis, 93 
Puncture, spinal, 27 
Pupil, irregularities of, 63 
Pupillary reflex, 33 
Pupils in leptomeningitis, 83 

in multiple neuritis, 83 

in tubercular meningitis, 94 
Purulent meningitis, 78. See also Lepto- 
meningitis. 
Pyramidal tracts, effect of lesions of, 351 



Qualitative change, 47 
Quantitative change, 46 
Quincke's disease, 545 



934 



INDEX. 



Quincke's lumbar puncture, 27 
in serous meningitis, 98 
in spinal leptomeningitis, 283 
Quinin in aural vertigo, 140 
in chorea, 569 
in multiple neuritis, 336 

sclerosis, 487 
in neuralgia, 664 



Rabies, 556 

Raptus melancholicus, 800 
Raynaud's disease, 540 

course and prognosis of, 542 
diagnosis of, 542 
etiology of, 540 
symptoms of, 541 
treatment of, 542 
Reaction, hemianopic pupillary, 104 

myasthenic, 49 

myotonic, 48 

of degeneration, 46 
in facial paralysis, 128 
partial, 47 

Wassermann, 25 

in cerebral syphilis, 494 
Reasoning mania, 787 
Reciprocal insanity, 724 
Rectus clonus, 37 

reflex, 37 
Recurrent mania, 787 

multiple neuritis, 332 
Red cerebral softening, 225 
Referred sensation, 54 
Reflected tone, 737 
Reflex, abdominal, 35 

Achilles tendon, 37 

anal, 38 

sphincteric, 38 

bulbocavernous, 447 

ciliary, 33 

cremasteric, 38 

disorders in insanity, 753 

epigastric, 35 

heel-tendon, 37 

mandibular, 34 

palpebral, 33 

patellar, 36 

pharyngeal, 34 

plantar, 37 

pupillary, 33 

rectus, 37 • 

sphincter, 38 

supra-orbital, 33 

triceps, 35 

virile, 38,, 447 
Reflexes, 32 

in anterior poliomyelitis, 393 

in hysteria, 618, 619, 628 

in lesions of spinal cord, 349 

in multiple cerebrospinal sclerosis, 754 
neuritis, 323 

in myelitis, 368 

in myoclonus epilepsy, 648 

in paraplegic state, 375 

in progressive muscular atrophy with 
cord-lesions, 412 



Reflexes in spinal tumors, 384 

in tabes dorsalis, 441 

of lower extremity, 35 

of upper extremity, 34 
Refraction, errors of, importance of, 63 
Refusal of food, management of, 780 
Regeneration of a divided nerve, 288 
Regression, law of, 736 
Resection of nerve-roots in tabes dorsalis, 

462 
Residence, importance of, 20 
Respiration in leptomeningitis, 84 

in tubercular leptomeningitis, 93 
Respiratory organs, examination of, 24 
Rest in multiple neuritis, 336 

in neuritis, 293 

in sciatic neuritis, 314 
Rest-cure, 773 
Retina, diseases of, 105 
Retinitis, 105 
Retrograde amnesia, 742 
Retropulsion, 577 
Reversion, 690 

Rheumatism, relation of, to chorea, 560 
Right-handedness, cause of, 169 
Rigidity in tubercular leptomeningitis, 93 

muscular, in leptomeningitis, 72 
Rhine's test, 65 

Robertson pupillary sign in tabes, 443 
Romberg, sign of, 435 

symptoms, 30 
Rontgen rays in brain disease, 198 
Rumination, 151 



Sagittal line, 174 

Salicylate of soda in auto-intoxication, 

776 
Salicylates in adiposis dolorosa, 513 

in anterior poliomyelitis, 396 

in facial paralysis, 131 

in Landry's paralysis, 380 
Saline solution in cerebral softening, 232 
Salol in auto-intoxication, 776 

in epilepsy, 652, 858 

in multiple neuritis, 336 

in myelitis, 372 
Saltatory chorea in hysteria, 630 
Salvarsan as preventive of paresis, 770 

in cerebral syphilis, 499 

in paralytic dementia, 826 

in tabes dorsalis, 459 
Sarcoma of brain, 259 
Scanning speech, 68 
Scaphocephaly, 696 
Schnauzkrampf, 808 
Sciatic nerve, great, lesion of, 309 

neuritis, 310. See also Neuritis. 

scoliosis, 312 
Sclerodactylie, 534 
Scleroderma, 534 

etiology of, 534 

symptoms of, 535 

treatment of, 535 
Scleroma adultorum, 534 
Sclerose en plaques, 479 
Scleroses of spinal cord, combined, 463 



INDEX. 



935 



Sclerosis, amyotrophic lateral, 406 

disseminated, 479 

multiple cerebrospinal, 479. See also 
Multiple cerebrospinal sclerosis. 

of posterior columns of cord, 428. See 
also Tabes dorsalis. 

of spinal cord from vegetable intoxi- 
cants, 476 

posterolateral, 463. See also Com- 
bined sclerosis. 
Scoliosis, sciatic, 312 
Scotch douche, 775 
Scotoma, central, 104 
Scotomata, 64 
Scriveners' palsy, 585 
Scurvy, Alpine, 476 

Secondary dementia, 810. See also De- 
mentia. 
Secretory disorders in insanity, 753 
Sedatives in leptomeningitis, 88 
Senile chorea, 572 

dementia, 810, 811. See also De- 
mentia. 

hypochondriasis, 812 

Korsakoff's psychosis, 812 

mania, 812 

melancholia, 812 

paranoid condition, 812 

psychoses, 810, 813 
Senility in etiology of insanity, 723 
Sensation, disorders of, in insanity, 729 
intensity of, 734 
qualitative, 729 
tone of, 734 

general consideration of, 49 

referred, 54 

testing and examination of, 50 
Sensibility, deep, 55 

epicritic, 55 

hallucinations of, 730 

illusions of, 734 

protopathic, 55 
Sensory conditions, 49 

cortical localization, 172 

disorders, actions induced by, 749 
in insanity, 752 

disturbances from brain-lesion, 195 

function, anomalies of, 712 

paths, 186 

tone, disorders of, 734 
Serous meningitis, 97. See also Menin- 
gitis, serous. 
Serum, antistreptococcus, in chorea, 569 

Flexner's, in diplococcus variety of 
meningitis, 90 
in leptomeningitis, 88 
Seventh cranial nerve. See Facial 

nerve. 
Sex in etiology of insanity, 689 
Shaking palsy, 574 
Shingles, 337. See also Herpes zoster. 
Shoulder, center for movements of, 171 
Sight, affections of, in tubercular lepto- 
meningitis, 93 

examination of, 62 

hallucinations of, 730 
Sign, Kernig's, in leptomeningitis, 82 



Sign, Kernig's, in tetanus, 553 

leg, in tetany, 539 
Signal symptom, 32, 195 
Simulo in epilepsy, 857 
Sinus thrombosis, 234 
infective, 236 
cavernous, 237 
lateral, 238 
longitudinal, 239 
symptoms of, 237 
treatment of, 239 
marantic, 235 
diagnosis of, 235 
prognosis of, 236 
symptoms of, 235 
Sinuses, cerebral, anatomy of, 233 
Sixth nerve, anatomical considerations 
of, 109 
effect of division of, 110 
Skin, anomalies of, 712 

trophic disturbances of, 39 
Sleep, disorders of, 666 

drunkenness, 671 

importance of, in diagnosis, 23 

palsy, 300, 673 

physical features of, 666 

ptosis, 673 

requirements for, 667 
Sleeping sickness, 673 
Smell, center for, 173 

examination of, 66 

hallucinations of, 730 

illusions of, 734 

loss of, 100 
Sodium iodid in cerebrospinal syphilis, 

498 
Softening, cerebral, 224. See also Cere- 
bral softening. 
Somnambulism, 669 
Somnolentia, 671 
Sounds, subjective, 66 
Space sense, disturbance of, 66 
Spasmodic asthma, 145. See also 
Asthma, bronchial. 

tabes, 463 

torticollis, 151, 608 

wryneck, 151 
Spasmogenic point or zone, 619 
Spasms, 31 

clonic, 31 

facial, 124, 608 

from cord-lesions, 347 

hypoglossal, 154 

hysterical rhythmical, 630 

idiopathic muscular, 38 

laryngeal, 144 

lingual, 154 

masticatory, 119 

mimic, 606 

occupation, 585 

of ocular muscle, 115 

of spinal accessory nerve, 151 

pharyngeal, 141 

tonic, 31 
Spastic paraplegia, hereditary, 475. See 

also Hereditary spastic paraplegia. 
Special senses, examination of, 62 



936 



INDEX. 



Speech, anomalies of, 713 
center for, 172, 176 
examination of, 67 
Sphincter reflex, 38 
Spina bifida, 386 

diagnosis of, 387 
etiology of, 387 
occulta, 386 
prognosis of, 387 
symptoms of, 387 
treatment of, 388 
Spinal accessory nerve, anatomical con- 
siderations of, 151 
paralysis of, 153 
spasm of, 151 
arteries, anterior, 342 

posterior, 346 
cord, anatomical considerations of, 340 
circulation in, 342 
combined sclerosis of, 463. See 

also Combined sclerosis. 
disabling transverse lesions of, table 

of symptoms, 353-359 
glioma of, 383 
hemorrhage into, 362 
in brain tumors, 263 
indiscriminate lesions of, 362 
lesions of, combined, in anemias and 
cachexias, 466 
cross, table of symptoms in, 353- 

359 
in tabes dorsalis, 432 
localization of, vertical, 347 
location of anesthesia in, 55 
motor symptoms of, 347 
of gray matter of, 388 
of one lateral half of, 56 
reflexes in, 349 
sensory symptoms of, 349 
trophic conditions in, 350 
vasomotor disturbance in, 350 
vertical localization of, 347 
visceral symptoms in, 350 
white matter of, 427 
localization of, 340 
relation of lesions and diseases of, 352 
to body surface, 341 
to vertebrae, 341 
segments, relation of anesthesia to, 
55 
to cutaneous areas, 56, 59 
subdural cysts of, 384 
symptoms, functions of, 348 
syphilis of, 495. See also Syphilis, 

spinal. 
thrombotic softening of, 364 
transverse sections of, 343 
traumatic lesions of substance of, 

362 
tumors of, 382 
douche, 775 

fluid in cerebrospinal syphilis, 494 
leptomeningitis, acute, 280 

chronic, 284 
meningeal hemorrhage, 284 
meninges, tumors of, 382 
meningitis, 278 



Spinal nerves, division of, 287 

histological changes in, 287 
muscular symptoms of, 288 
symptoms of, 287 
treatment of, 289 
injuries and diseases of, 286 
lesions of, in tabes dorsalis, 431 
pachymeningitis, 278 
special lesions of, 297 
stretching in family ataxia, 475 

in tabes dorsalis, 459 
symptoms in tubercular leptomen- 
ingitis, 95 
syphilis, 495. See also Syphilis, 

spinal. 
tumors, 382 
course of, 385 
diagnosis of, 385 
location of, 386 
morbid anatomy of, 383 
prognosis of, 385 
reflexes in, 384 
symptoms of, 384 
treatment of, 386 
Spinal puncture, 27 
Spine, concussion of, 658 
Sporadic cretinism, 516 
Spurious ankle-clonus, 38 
Squamosal point, 175 
Squint, importance of, 63 
St. Vitus' dance, 558 
Stahl ear, No. 1, 707, 708 

No. 2, 708 
Stammering, 68 
Staphylococcus areus in chorea, 562 

pyogenes in chorea, 562 
Static ataxia, 30 
Status epilepticus, 646 
Steeple-shaped skull, 714 
"Steppage," 321 
Stereoagnosis, 51 

Stereognosis, cerebral localization, 172 
Stereognostic sense, 51 

impairment of, in tabes dorsalis, 440 
Stereotyped movements, 743, 750 
Stereotypy in dementia prsecox, 805 
Sthenic loss in cerebellar disease, 191 
Stigmata hereditatis, 691 

of degeneracy in nervous disease, 21 
of degeneration in insanity, 691 
Stimulants in leptomeningitis, 88 
Storm center, 194 
Strain, physical and mental, in etiology 

of insanity, 713 
Stream of thought, actions induced by 

disorders of, 750 
Streptococcus in chorea, 562 

in leptomeningitis, 79 
"Stroke," apoplectic, 212 
Strophanthus in exophthalmic goiter, 532 
Struma exophthalmica, 523 
Strychnin in anterior poliomyelitis, 397 
in brain-tumor, 272 
in bronchial asthma, 146 
in cerebral hemorrhage, 222 

softening, 232 
in chorea, 569 



INDEX. 



937 



Strychnin in exophthalmic goiter, 532 
in nervous deafness, 135 
in neuralgia, 665 
in neurasthenia, 601 
in neuritis, 293 
in polioencephalitis superior chronica, 

159 
in spinal progressive muscular atrophy, 
414 
Stupor, 743 

manic, 782 
Stuttering, 68 
Subdural cysts of spinal cord, 384 

space, 72 
Subjective sounds, hearing of, 67 
Suicidal tendencies, management of, 780 
Sulphonal in chorea, 569 
in insanity, 778 
in mania, 789 
Summary remembrance, 742 
Supra-orbital reflex, 33 
Suprascapular nerve, lesions of, 299 
Syllable stumbling, 68 
Symelus, 711 

Symmetrical lipomatosis, 550 
Sympathetic nerve, effect of division of, 

111 
Symptom, extension, 194 
group of Weber, 113 
invasion, 194 
Romberg, 30 
signal, 32, 195 
Symptomatic disorders, 660 
Symptoms at a distance, 198 
diffused, 195 
localized, 195 
Syndactyly, 711 
Syndrome, Benedict-Weber, 190 

thalamic, 190 
Synergy, 29 
Syphilis, cerebral, 489 
arterial form of, 492 
diagnosis of, 493 
general symptoms of, 490 
gummatous form of, 493 
headache in, 491 
meningeal form of, 492 
mental symptoms of, 493 
prognosis of, 494 
salvarsan in, 499 
special symptoms of, 491 
spinal fluid in, 494 
treatment of, 495, 498 
Wassermann reaction in, 494 
hereditary cerebrospinal, 498 
in etiology of idiocy, 868 
of insanity, 717 

of paralytic dementia, 814, 823, 824 
inherited, predisposing to nervous dis- 
ease, 18 
of cranial nerves, 490 
of nervous system, 487 

acquired, 488 
spinal, diagnosis of, 497 
prognosis of, 497 
treatment of, 498 
Syphilitic ataxic paraplegia, 496 



Syphilitic cerebral arteritis, 489 
meningitis, 489 

cerebritis, 489 

meningomyelitis, 495 

mental disease, 493 

myelitis, 496 

neuritis, 497 

pseudoparesis, 493 

softening of cord, 496 

spinal meningitis, 495 
paralysis, 497 

tumors of brain, 261 
Syphilophobia, 493 
Syringobulbia, 403 
Syringomyelic dissociation, 401 
Syringomyelitis, 398 

anesthesia in, 401 

arthropathies in, 403 

atrophy in, 402 

clinical forms of, 404 

course of, 403 

diagnosis of, 405 

etiology of, 398 

morbid anatomy of, 399 

Morvan's type of, 404 

motor disturbances in, 402 

prognosis of, 405 

sensory disturbances in, 401 

symptoms of, 400 

treatment of, 405 

trophic features of, 402 

unusual symptoms of, 403 

vasomotor symptoms of, 403 



Tabes, combined, 463 
dorsalis, 428 

amyotropia in, 453 

analgesia in, 439 

aneurysm in, 449 

aspirin in, 462 

ataxia, in, 435 

auditory symptoms in, 444 

blood in, 449 

bones in, 449 

cerebral disturbances in, 454 

constipation in, 446 

course of, 455 

cramps in, 439 

crises in, 445 

diagnosis of, 457 

diarrhea in, 446 

differential diagnosis of, 457 

disorders of generative function in, 
447 
of intestines in, 446 
of nutrition in, 449 
of osseous system in, 449 
of respiratory apparatus in, 448 
of skin in, 453 
of stomach in, 445 
of urinary apparatus in, 446 
of vascular apparatus in, 448 

disturbance of the reflexes in, 441 

etiology of, 428 

flat-foot in, 452 

gastric crises in, 445 



938 



INDEX. 



Tabes dorsalis, general paresis and, 818 

girdle sensation in, 439 

glycosuria in, 447 

herpes zoster in, 453 

hyperalgesia in, 440 

impairment of stereognostic sense in, 
440 

impotence in, 447 

involuntary movements in, 437 

juvenile, 456 

labyrinthine disturbance in, 445 

laryngeal crises in, 448 

lightning pains in, 438 

mercury in, 459 

morbid anatomy of, 430 

motor disturbances in, 435 

muscles in, lack of tonicity of, 442 

muscular atrophies in, 453 

myoidism in, 437 

nasal crises in, 445 

neosalvarsan in, 459 

nephritic crises in, 447 

optic nerve in, 444 

pains in, 438 

palsies in, 437 

perforating ulcer in, 453 

pharyngeal crises in, 448 

phenacetin in, 462 

prognosis of, 458 

ptosis in, 443 

pupils in, 443 

rarefying osteitis in, 450 

rectal crises in, 446 

resection of nerve-roots in, 462 

Robertson's sign in, 443 

Romberg's sign in, 435 

salvarsan in, 459 

sensory disturbances in, 438 

spontaneous fractures in, 449 

squint in, 443 

stroke in, 448 

symptoms of, 435 

tabetic arthropathy in, 450 

tabulation of, 454 

temperature in, 449 

treatment of, 459 

trophic cutaneous disorders in, 453 
disorders in, 449 

urotropin in, 462 

valvular disease in, 448 

varieties of, 455 

visceral disorders in, 445 

visual disturbances in, 443 

vomiting in, 445 

Westphal's sign in, 441 
spasmodic, 463 
Tabetic arthropathy, 450 
crises, 445 
cuirass, 440 
fractures, 449 
joint, 451 
Tache cerebrale in leptomeningitis, 83 

in tubercular leptomeningitis, 94 
Tachycardia, 147 
Tactile sense, 50 

testing of, 50 
Taste, center for, 173 



Taste, electrical testing of, 49 

examination of, 66 

hallucinations of, 730 

illusions of, 734 

in facial paralysis, 128 

loss of, 67 

perversions of, 67 

subjective sensations of, 67 
Teeth, anomalies of, 705 
Temperature changes in insanity, 755 

examination of, 25 

in anterior poliomyelitis, 392 

in cerebral hemorrhage, 213 

in leptomeningitis, 83 

in spinal leptomeningitis, 282 

in tubercular leptomeningitis, 93 

localized elevation of, as a symptom in 
brain disease, 197 
Tender points in sciatic neuritis, 312 

of VaUeix, 662 
Tenderness as a symptom, 58 
of brain disease, 197 

in leptomeningitis, 83 

in multiple neuritis, 325 

in sciatic neuritis, 312 
Tendon-reflexes in leptomeningitis, 84 

in tubercular leptomeningitis, 93 
Tendons, trophic disorders of, 40 
Teratoma of brain, 262 
Test, Barany's labyrinthine, 138 

Ewald's labyrinthine, 138 

ophthalmic, in tubercular meningitis, 
96 

thermic, for labyrinthine disease, 138 

tuberculin, in tubercular meningitis, 96 
TetaniUa, 536. See also Tetany. 
Tetanus, 553 

antitoxin in, 555 

carbolic acid in, 555 

cathodal closing, 44 

cephalic, 554 

diagnosis of, 554 

etiology of, 553 

eucain in, 555 

head, 554 

hydrophobicus, 554 

Kernig's sign in, 553 

magnesium sulphate in, 555 

morbid anatomy of, 553 

morphin in, 555 

neonatorum, 554 

prognosis of, 554 

puerperal, 554 

symptoms of, 553 

treatment of, 555 

varieties of, 554 
Tetany, 536 

course of, 539 

diagnosis of, 539 

etiology of, 536 

leg sign in, 539 

prognosis of, 539 

symptoms of, 537 

treatment of, 550 
Thalamic syndrome, 190 
Thermic sense, testing of,_ 51 

tests for labyrinthine disease, 138 



INDEX. 



939 



Thermo-analgesia, 54 
Thermoanesthesia, 54 
Third nerve, affection of, in leptomenin- 
gitis, 83 

anatomical considerations of, 109 

effect of division of, 110 
Thomsen's disease, 580 

diagnosis of, 582 

etiology of, 580 

morbid anatomy of, 581 

symptoms of, 581 

treatment of, 583 
Thoracic nerve, posterior, lesions of, 298 
Thought-inhibition, 743 
Thrombosis a cause of cerebral softening, 

224, 232 
of arteries of spinal cord, 364 
of sinus, 232. See also Sinus throm- 



Thrombotic softening of spinal cord, 364 
Thyroid extract in myxedematous idiocy, 
907 

gland, trophoneuroses related to, 513 
in adiposis dolorosa, 513 

treatment, 522 
Thyroidin, 523 
Tic, motor, 606 

douloureux, 31, 608 

etiology of, 607 

treatment of, 608 
Tinnitus, 133, 134 
Toe-sign of Babinski, 37 
Tongue, anomalies of, 705 

motor center for, 171 

paralysis of, 155 
Tonic convulsions, 32 

excess in cerebellar disease, 192 

spasm, 31 
Topical symptoms in brain disease, 197 
Torticollis, mental, 152, 608 

spasmodic, 153, 608 
Torus palatinus, 701, 705 
Toxic influences in etiology of insanitv, 

714 
Trance, hysterical, 627 
Transitory mania, 787 
Transverse myelitis, 366 
Traumatic idiocy, 866 

insanity, 720 

neuromata, 294 

neuroses, 658 

psychosis, 659 
Tremors, 30 

family, 584 

fibrillary, 30 

handwriting in, 31 

importance of, 30 

intention, 30 

testing for, 31 

volitional, 30 
Trephining in cerebral hemorrhage, 222 

in leptomeningitis, 89 
Triceps reflex, 35 

Trifacial nerve, anatomical considera- 
tions of, 117 
cortical diseases of, 119 
disease of branches of, 122 



Trifacial nerve, diseases of, 117 
nuclear disease of, 119 
peripheral intracranial affections of, 

119 
neuralgia, 663 
neuritis, 122 
Trigeminus. See Trifacial nerve. 
Trigonocephalus, 696 
Trinitrin in angina pectoris, 150 

in Raynaud's disease, 542 
Trional in chorea, 569 
in epilepsy, 653 
in insanity, 778 
in mania, 789 
in neurasthenia, 601 
Trismus, 553 
Trochanteric point, 312 
Trophic conditions, 39 

disorders in insanity, 753 
Tropho-edema, chronic hereditary, 552 
Trophoneuroses, 502 
hypertrophic, 548 
related to hypophysis cerebri, 502 
to parathyroid gland, 513 
to thyroid gland, 513 
vascular, 540 
Trousseau's sign of tetany, 538 
Trunk, center for movements of, 171 

nerves of, lesions of, 308 
Tubercle of the brain, 258 
Tubercular meningitis, 91. See also 

Leptomeningitis, tubercular. 
Tuberculin test in tubercular meningitis, 

96 
Tuberculosis in etiology of insanitv, 

718 
Tumors in cerebello-pontine angle, symp- 
toms presented by, 193 
in frontal region, vertigo with, 192 
of brain, 258 

changes in cord in, 263 
course of, 26 
diagnosis of, 268 
etiology of, 258 
headache in, 264 
hemiplegia in, 267 
pathological anatomy of, 258 
prognosis of, 270 
symptoms of, 263 
syphilitic, 261 
treatment of, 271 
vertigo in, 266 
visual field in, 64 
vomiting in, 266 
of nerves, 293. See also Neuromata. 
of spinal cord, 382 

meninges, 382 
pituitary, with acromegaly, 262 

with hydrocephalus, 273 
pseudocerebral, 269 
Tuning-fork in testing hearing, 65 
Turkish baths in multiple neuritis, 

336 
Twelfth cranial nerve. See Hypoglossal 

nerve. 
Typhoid bacillus in leptomeningitis, 
79 



940 



INDEX. 



Ulnar nerve, lesions of, 302 
Uncinate fits, 643 
Unproductive mania, 782 
Unsymmetrical hypertrophies, 552 
Urine, condition of, 26 

in insanity, 754 

in leptomeningitis, 84 

incontinence of, 23 
Urotropin in tabes dorsalis, 462 
Urticaria, giant, 545 

in leptomeningitis, 84 



Vagus, anatomical considerations of, 140 

cardiac branches of, 147 

disease of, 141 

gastric branches of, 152 

laryngeal branches of, 141 

pharyngeal branches of, 141 
^ pulmonary branches of, 145 
Valerian in myoclonia, 573 
Valleix, tender points of, 662 
Vascular disorders in insanity, 756 
^ trophoneuroses, 540 
Veins, cerebral, anatomy of, 233 
Venereal history, importance of, in diag- 
nosis of nervous disease, 19 
Venesection in cerebral hemorrhage, 222 
Ventil operation for idiocy, 907 
Veratrum in cerebral hemorrhage, 222 

viride in hematomyelia, 364 
Verbigeration, 744, 785 
Veronal in insanity, 778 

in insomnia, 669 
Verrticktheit, 679 
Vertebral segments, relation of maximal 

points of pain to, 59 
Vertical localization of a cord-lesion, 347 

point, 174 
Vertigo as symptom, 196 

aural, 136. See also Aural vertigo. 

in brain lesions, 196 

in cerebellar disease, 192 

in disease of labyrinth, 66 

in epilepsy, 644, 646 

in hysteria, 627 

in multiple cerebrospinal sclerosis, 485 

in tumors of brain, 266 
of frontal region, 192 
Vestibular nerve, diseases of, 136 
Violence in insane, management of, 774 
Virile reflex, 37, 447 
Visceral diseases, areas of pain and, 58 

pia, 72 
Vision, center for, 172 

electrical testing of, 49 

illusions of, 733 

in multiple neuritis, 325 

testing of, 63 
Visual aphasia, 182 

field, 64 

functions, cortical representation, 172 
in brain-tumor, 265 
in nervous diseases, 64 

testing of, 64 

tract, 101 



Volitional tremor, 30 

Vomiting as a cerebral symptom, 196 
in leptomeningitis, 81 
in lesions of spinal cord, 350 
in tabes dorsalis, 445 
in tubercular meningitis, 93 
in tumor of brain, 266 
projectile, as a symptom, 196 

Von Pirquet's test in tubercular meningi- 
tis, 96 



Wahnsinn, 679 
Wassermann reaction, 25 

in cerebral syphilis, 494 
Wasting palsy, 407 
Weakness, muscular, in leptomeningitis, 

82 
of judgment, 748 
Weber, symptom group of, 113 
Weber's test, 445 

Weichselbaum's diplococcus in lepto- 
meningitis, 79 
Werdnig-Hoffman type of muscular 

atrophy, 423 
Wernicke's hemianopic pupillary reac- 
tion, 104 
sign, 34 
Westphal's sign, 441 
Whisky in angina pectoris, 150 
White cerebral softening, 225 

matter of cord, lesions of, 427 
Wildermuth's Aztec ear, 708 

ear, 708, 710 
Word faculties, 176 

stability of, 178 
Word-association method of testing intel- 
ligence and emotions, 763 
Word-blindness, explanation of produc- 
tion of, 104 
lesion causing, 173 
Word centers, 176 
Word-deafness, 134, 180 

lesion causing, 173 
Wormian bones, significance of, 698 
Wrist, center for movements of, 171 
Wrist-clonus, 35 
Writer's cramp, 585 

course of, 589 

diagnosis of, 590 

etiology of, 585 

motor disorders of, 587 

pathology of, 586 

prognosis of, 590 

sensory disorders in, 589 

symptoms of, 587 

treatment of, 590 
Written speech, perception of, 69 
Wryneck, spasmodic, 151 



Yellow cerebral softening, 225 



Zona, 337. See also Herpes zoster. 
Zoster, 337. See also Herpes zoster. 



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IO SAUNDERS' BOOKS ON 



Eisendrath's 
Surgical Diagnosis 

A Text=Book of Surgical Diagnosis. By Daniel N. Eisendrath, 
M.D., Professor of Surgery in the College of Physicians and Surgeons, 
Chicago. Octavo of 885 pages, with 574 entirely new and original 
text-illustrations and some colored plates. Cloth, $6.50 net; Half 
Morocco, $8.00 net. 

THE NEW (2d) EDITION 

Of first importance in every surgical condition is a correct diagnosis, for upon 

this depends the treatment to be pursued ; and the two — diagnosis and treatment 

constitute the most practical part of practical surgery. Dr. Eisendrath takes up 
each disease and injury amenable to surgical treatment, and sets forth the means 
of correct diagnosis in a systematic and comprehensive way. Definite directions 
as to methods of examination are presented clearly and concisely, providing for 
all contingencies that might arise in any given case. Each illustration indi- 
cates precisely how to diagnose the condition considered. 

Surgery, Gynecology, and Obstetrics 

"The book is one which is well adapted to the uses of the practising surgeon who desires 
information concisely and accurately given. . . . Nothing of diagnostic importance is omitted, 
yet the author does not run into endless detail." 



Eisendrath's Clinical Anatomy 

A Text=Book of Clinical Anatomy. By Daniel N. Eisendrath, 
A.B., M.D., Professor of Surgery in the College of Physicians and 
Surgeons, Chicago. Octavo of 535 pages, illustrated. Cloth, $5.00 
net; Half Morocco, $6.50 net. 

THE NEW (2d) EDITION 

This new anatomy discusses the subject from the clinical standpoint. A por- 
tion of each chapter is devoted to the examination of the living through palpation 
and marking of surface outlines of landmarks, vessels, nerves, thoracic and 
abdominal viscera. The illustrations are from new and original drawings and 
photographs. This edition has been carefully revised. 

Medical Record, New York 

" A special recommendation for the figures is that they are mostly original and were 
made for the purpose in view. The sections of joints and trunks are those of formalinized 
cadavers and are unimpeachable in accuracy." 



SURGER Y AND ANA TOMY 1 1 



Fenger Memorial Volumes 

Fenger Memorial Volumes. Edited by Ludvig Hektoen, M. D., 
Professor of Pathology, Rush Medical College, Chicago. Two octavos 
of 5 25 pages each. Per set : Cloth, $15.00 net ; Half Morocco, $18.00 net. 

LIMITED EDITION 

These handsome volumes consist of all the important papers written by the late 
Christian Fenger, for many years professor of surgery at Rush Medical College, 
Chicago. Not only the papers published in English are included, but also those 
which originally appeared in Danish, German, and French. 

The name of Christian Fenger typifies thoroughness, extreme care, deep re- 
search, and sound judgment. His contributions to the advancement of the world's 
surgical knowledge are indeed as valuable and interesting reading to-day as at 
the time of their original publication. They are pregnant with suggestions. 
Fenger' s literary prolificacy may be judged from this memorial volume — over 
1000 pages. 

Sobotta and McMurrich's 
Human Anatomy 

Atlas and Text=Book of Human Anatomy. In Three Volumes. By 
J. Sobotta, M.D., of Wurzburg. Edited, with additions, by J. Playfair 
McMurrich, A. M., Ph. D., Professor of Anatomy, University of 
Toronto, Canada. Three large quartos, each containing about 250 
pages of text and over 300 illustrations, mostly in colors. Per volume : 
Cloth, $6.00 net ; Half Morocco, $7.50 net. 

Edward Martin, M.D., Professor of Clinical Surgery, University of Pennsylvania 

" This is a piece of bookmaking which is truly admirable, with plates and text so well 
chosen and so clear that the work is most useful to the practising surgeon." 



Campbell's Surgical Anatomy 

A Text=Book of Surgical Anatomy. By William Francis Camp- 
bell, M. D., Professor of Anatomy, Long Island College Hospital. 
Octavo of 675 pages, with 319 original illustrations. Cloth, $5.00 net. 

SECOND EDITION 

This is in the fullest sense an applied anatomy — an anatomy that will be of 
inestimable value to the surgeon because only those facts are discussed and only 
those structures and regions emphasized that have a peculiar interest to him. 

Boston Medical and Surgical Journal 

" The author has an excellent command of his subject, and treats it with the freedom and 
the conviction of the experienced anatomist. He is also an admirable clinician." 



SAUXDERS' BOOKS ON 



Moynihan's Duodenal Ulcer 

Duodenal Ulcer. By B. G. A. Moynihan, M.S. (London), F.R.C.S., 
Leeds, England. Octavo of 486 pages, illustrated. Cloth, $5.00 net; 
Half Morocco, $6.50 net. 

THE NEW (2d) EDITION 

For this edition the work has been entirely reset and brought up to date. All 
the cases operated upon since the appearance of the first edition have been in- 
cluded and a new chapter added on Jejunal and Gastro-jejunal Ulcers. 



Moynihan's Abdominal Operations 

Abdominal Operations. By B. G. A. Moynihan, M. S. (London), 
F. R. C. S., Leeds, England. Octavo, beautifully illustrated. 

THE NEW (3d) EDITION— PREPARING 

Edward Martin, M. D., University of Pennsylvania. 

"It is a wonderfully good book. He has achieved complete success in illustrating, both 
by words and pictures, the best technic of the abdominal operations now commonly performed.' 



Moynihan on Gall-stones 

Gall=Stones and Their Surgical Treatment. — By B. G. A. Moyni- 
han, M. S. (London), F. R. C. S., Leeds, England. Octavo of 458 pages, 
illustrated. Cloth, $5.00 net; Half Morocco, 36.50 net. 

THE NEW (2d) EDITION 

Mr. Moynihan, in revising his book, has made many additions to the text, so 
as to include the most recent advances. Especial attention has been given to a 
detailed description of the early symptoms in cholelithiasis, enabling a diagnosis 
to be made in the stage in which surgical treatment can be most safely adopted. 

British Medical Journal 

" He expresses his views with admirable clearness, and he supports them by a large num- 
ber of clinical examples, which will be much prized by those who know the difficult problems 
and tasks which gall-stone surgery not infrequently presents." 



Dannreuther's Minor and Emergency Surgery 

Minor and Emergency Surgery. By Walter T. Dannreuther, M.D., Surgeon 
to St. Elizabeth's Hospital and to St. Bartholomew's Clinic, New York City. l2mo of 225 
pages, illustrated. Cloth, $1.25 net. 

ILLUSTRATED 

Dr. Dannreuther emphasizes just those points most necessary in emergency work, giving numerous hints 
and suggestions that cannot help but be of great value to you in emergency work and in minor operations. 



SURGER Y AND ANA TOMY 1 3 

Schultze and Stewart's Topographic Anatomy 

Atlas and Text=Book of Topographic and Applied Anatomy. By Prof. 
Dr. 0. Schultze, of Wiirzburg. Edited, with additions, by George D. 
Stewart, M. D., Professor of Anatomy and Clinical Surgery, University 
and Bellevue Hospital Medical College, N. Y. Large quarto of 189 pages, 
with 25 colored figures on 22 colored lithographic plates, and 89 text-cuts, 60 
in colors. Cloth, $5,50 net. 

Griffith's Hand-Book of Surgery 

A Manual of Surgery. By Frederic R. Griffith, M. D., Surgeon to the 
Bellevue Dispensary, New York City. i2mo of 579 pages, with 417 illus- 
trations. Flexible leather, $2.00 net. 

Keen's Addresses and Other Papers 

Addresses and Other Papers. Delivered by William W. Keen, M. b., 
LL.D., F. R. C. S. (Hon.), Professor of the Principles of Surgery and of Clin^ 
ical Surgery, Jefferson Medical College, Philadelphia. Octavo volume of 
441 pages, illustrated. Cloth, $3.75 net 

Keen on the Surgery of Typhoid 

The Surgical Complications and Sequels of Typhoid Fever. By Wm. W b 

Keen, M.D., LL.D., F.R.C.S. (Hon.), Professor of the Principles of Surgery 
and of Clinical Surgery, Jefferson Medical College, Philadelphia, etc, 
Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. 

Gould's Operations on Intestines and Stomach 

The Technic of Operations Upon the Intestines and Stomach. By Al- 
fred H. Gould, M. D., of Boston. Large octavo, with 190 original illustra- 
tions, some in colors. Cloth, $5.00 net; Half Morocco, $6.50 net. 

Bier's Hyperemia second Edition 

Bier's Hyperemic Treatment in Surgery, Medicine, and the Specialties : 
A Manual of its Practical Application. By Willy Meyer, M. D., Professor 
of Surgery at the New York Post-Graduate Medical School and Hospital ; and 
Prof. Dr. Victor Schmieden, Assistant to Prof. Bier, University of Berlin, 
Germany. Octavo of 280 pages, with original illustrations. Cloth, $3.00 net. 

" We commend this work to all those who are interested in the treatment of infections, either acute or 
chonic, for it is the only authoritative treatise we have in the English language. "—New York State 
Journal of Medicine. 

Morris* Dawn of the Fourth Era in Surgery 

Dawn of the Fourth Era in Surgery and Other Articles. By 

Robert T. Morris, M. D., Professor of Surgery, New York Post-Graduate 
Medical School and Hospital. i2mo of 145 pages, illustrated. $1.25 net. 



14 SAUNDERS* BOOKS OJV 

Haynes' Anatomy 

A Manual of Anatomy. By Irving S. Haynes, M.D., Professor of Prac- 
tical Anatomy, Cornell University Medical College. Octavo, 680 pages, 
with 42 diagrams and 134 full-page half-tones. Cloth, $2.50 net. 

American Pocket Dictionary New (8th) Edition 

The American Pocket Medical Dictionary. Edited by W. A. Newman 

Dorland, A. M., M. D., Editor "American Illustrated Medical Dictionary." 
677 pages. Full leather, limp, with gold edges, $1.00 net; with patent 
thumb index, $1.25 net. 

McClellan's Art Anatomy 

Anatomy in its Relation to Art. By George McClellan, M. D., Professor 
of Anatomy, Pennsylvania Academy of the Fine Arts. Quarto volume, 9 by 
12^2 inches, with 338 original drawings and photographs, and 260 pages of 
text. Dark blue vellum, $10.00 net; Half Russia, $12.50 net. 

Fowler's Surgery in Two volumes 

A Treatise on Surgery. By George R. Fowler, M. D., Emeritus Pro- 
fessor of Surgery, New York Polyclinic. Two imperial octavos of 725 pages 
each, with 888 original text-illustrations and 4 colored plates. Per set : 
Cloth, $15.00 net ; Half Morocco, $18.00 net. 

International Text-Book of Surgery second Edition 

The International Text=Book of Surgery. In two volumes. By Ameri- 
can and British authors. Edited by J. Collins Warren, M. D., LL. D., 
F. R. C. S. (Hon.), Professor of Surgery, Harvard Medical School ; and A. 
Pearce Gould, M. S., F. R. C. S., of London, England. Vol. I. : General 
and Operative Surgery. Royal octavo, 975 pages, 461 illustrations, 9 full- 
page colored plates. Vol. II. : Special or Regional Surgery. Royal octavo, 
1 122 pages, 499 illustrations, and 8 full-page colored plates. Per volume : 
Cloth, $5.00 net ; Half Morocco, $6.50 net. 

American Text-Book of Surgery Fourth Edition 

American Text=Book of Surgery. Edited by W. W. Keen, M. D., 
LL. D., Hon. F. R. C. S., Eng. and Edin., and J. William White, 
M. D., Ph. D. Octavo, 1363 pages, 551 text-cuts and 39 colored and 
half-tone plates. Cloth, $7.00 net ; Half Morocco, $8.50 net. 

Robson and Cammidge on the Pancreas 

The Pancreas : Its Surgery and Pathology. By A. W. Mayo Robson, 
F. R. C. S., of London, England; and P. J. CammidGe, F. R. C. S., of 
London, England. Octavo of 546 pages, illustrated. Cloth, $5.00 net; 
Half Morocco, $6. 50 net. 



SURGER Y AND ANA TOM} . 1 5 



American Illustrated Dictionary The New 7th) Edition 

The American Illustrated Medical Dictionary. With tables 
of Arteries, -Muscles, Nerves, Veins, etc. ; of Bacilli, Bacteria, etc. ; 
Eponymic Tables of Diseases, Operations, Stains, Tests, etc. By W. A. 
Newman Dorland, M.D. Large octavo, t 107 pages. Flexible leather, 
$4.50 net; with thumb index, $5.00 net. 

Howard A. Kelly, M.D., Prof 'essor of Gynecology , Johns Hopkins University, Baltimore. 

"Dr. Dorland's dictionary is admirable. It is so well gotten up and of such con- 
venient size. No errors have been found in my use of it." 

Golebiewski and Bailey's Accident Diseases 

Atlas and Epitome of Diseases Caused by Accidents. By Dr. 

Ed. Golebiewski, of Berlin. Edited, with additions, by Pearce Bailey, 
M.D. Consulting Neurologist to St. Luke's Hospital, New York City. 
With 71 colored figures on 40 plates, 143 text-cuts, and 549 pages of 
text. Cloth, $4.00 net. In Saunders' Hand- Atlas Series. 

Helferich and Bloodgood on Fractures 

Atlas and Epitome of Traumatic Fractures and Dislocations 

By Prof. Dr. H. Helferich, of Greifswald, Prussia. Edited, with ad- 
ditions, by Joseph C. Bloodgood, M. D., Associate in Surgery, Johns 
Hopkins University, Baltimore. 216 colored figures on 64 lithographic 
plates, 190 text-cuts, and 353 pages of text. Cloth, $3.00 net. /// Saun- 
ders' Atlas Series. 

Sultan and Coley on Abdominal Hernias 

Atlas and Epitome of Abdominal Hernias. By Pr. Dr. G. Sul- 
tan, of Gottingen. Edited, with additions, by Wm. B. Coley, M. D., 
Clinical Lecturer and Instructor in Surgery, Columbia University, New 
York. 119 illustrations, 36 in colors, and 277 pages of text. Cloth, 
$3.00 net. In Saunders' Hand- Atlas Series. 

Warren's Surgical Pathology §££! 

Surgical Pathology and Therapeutics. By J. Collins Warren, 
M.D., LL.D., F.R.C.S. (Hon.), Professor of Surgery, Harvard Medical 
School. Octavo, 873 pages; 136 illustrations, 33 in colors. Cloth, 
$5.00 net; Half Morocco, $6.50 net. 

Zuckerkandl and DaCosta's Surgery f^jj 

Atlas and Epitome of Operative Surgery. By Dr. O. Zucker- 
kandl, of Vienna. Edited, with additions, by J. Chalmers DaCosta, 
M.D., Samuel D. Gross Professor of Surgery, Jefferson Medical Col- 
lege, Philadelphia. 40 colored plates, 278 text-cuts, and 410 pages of 
text. Cloth, $3.50 net. In Saunders 1 Atlas Series. 



16 SURGER V AND ANA TOMY 



Moore's Orthopedic Surgery 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professo* 
of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. 
Octavo of 356 pages, handsomely illustrated. Cloth, $2.50 net. 

" T i. he b 2° k is eminentl y practical. It is a sate guide in the understanding and treatment ot 
orthopedic cases. Should be owned by every surgeon and practitioner."— Annals of Surgery. 

Fowler's Operating Room New ( 3 d) Edition, Reset 

The Operating Room and the Patient. By Russell S. Fowler, M. D., 

Surgeon to the German Hospital, Brooklyn, New York. Octavo of 611 

pages, illustrated. Cloth, $3.50 net. 

Dr. Fowler has written his book for surgeons, nurses assisting at an operation, internes, 
and all others whose duties bring them into the operating room. It contains explicit 
directions for the preparation of material, instruments needed, position of patient, etc., 
all beautifully illustrated. 

Nancrede's Principles of Surgery New (2d) Edition 

Lectures on the Principles of Surgery. By Chas. B. Nancrede, M.D., 
LL.D., Professor of Surgery and of Clinical Surgery, University of Michigan, 
Ann Arbor. Octavo, 407 pages, illustrated. Cloth, #2.5u net. 

" We can strongly recommend this book to all students and those who would see something 
of the scientific foundation upon which the art of surgery is built."— Quarterly Medical Journal, 
Sheffield, England. 

Nancrede's Essentials of Anatomy. Seventh EdWon 

Essentials of Anatomy, including the Anatomy of the Viscera. By Chas, 
B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University 
of Michigan, Ann Arbor. Crown octavo, 388 pages ; 180 cuts. With an 
Appendix containing over 60 illustrations of the osteology of the body. Based 
on Gray 's Anatomy. Cloth, $1.00 net. In Saunders Question Compends. 

" The questions have been wisely selected, and the answers accurately and concisely given . "— = 
University Medical Magazine* 

Martin's Essentials of Surgery. Seve R£if e d d ition 

Essentials of Surgery. Containing also Venereal Diseases, Surgical Land- 
marks, Minor and Operative Surgery, and a complete description, with illus- 
trations, of the Handkerchief and Roller Bandages. By Edward Martin, 
A.M., M.D., Professor of Clinical Surgery, University of Pennsylvania, etc. 
Crown octavo, 338 pages, illustrated. With an Appendix on Antiseptic Sur- 
gery, etc. Cloth, $1.00 net. In Saunders' Question Compends. 

"Written to assist the student, it will be A undoubted value to the practitioner, containing as it 
does the essence of surgical work." — Boston Medical and Surgical Journal. 

Martin's Essentials of Minor Surgery, Band- 
aging, and Venereal Diseases. Seco £di^ e n vised 

Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By 

Edward Martin, A.M., M.D., Professor of Clinical Surgery, University oi 
Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. 

Cloth, $1.00 net. In Saunders 1 Question Compenas* 

"The best condensation of the subjects of which it treats yet placed before the profession,"-* 
The Medical News, Philadelphia. 



